Care of the Vascular Patient

1. Care of the Vascular Patient Stacey Becker, RN Angela Allen, ACNP

2. Open Abdominal Procedures Used to Treat the Following: • AAA’s (Abdominal Aortic Aneurysms) • TAA’s (Thoracic Aortic Aneurysms) • TAAA’s (Thorocoabdominal Aortic Aneurysms • Renal Artery Aneurysms • Renal Artery Stenosis or Renovascular Hypertension • Aortoilliac Occlusion • Superior Mesenteric Artery Stenosis • Removal of Infected Graft

3. Primary Procedures-Open • Open AAA repair • Open TAA repair • Open TAAA repair • Aortobifemoral bypass • Renal artery bypass • NAIS (Neo-aortoillac system) • SMA bypass

4. Aneurysms • 1.5 times the diameter of the adjacent non-aneurysmal vessel • Usually begin treatment of AAA in a good risk candidate at 5 cm-endovascular and closer to 5.5 cm for open repair • Usually begin treatment of TAA in good risk patient around 6.0 cm for endovascular and 6.5 or greater for open repair

5. Aneurysm Classification Supra-renal AAA Juxta-renal AAA Infra-renal AAA

6. Intraoperative-Open • All are done under General Anesthesia • Average time of operation is 2-6 hours • Usual incision is midline for abdominal and thorocoabdominal if also involving thoracic aorta • Thoracic procedures have lumbar spinal catheter to provide spinal cord protection • Estimated Blood Loss is 500-4000cc • Aggressive blood products and fluids are given

7. Open AAA Repair Transperitoneal Retroperitoneal

8. Aortobifemoral Bypass

9. TAAA Open Repair

10. Postoperative Care-Open • All open procedures go to the ICU first • Stay in the ICU until extubated and can protect their airway • Many require vasoactive drips • Huge fluid shifts take place in the immediate post op period with monitoring of such • Pain control is an issue • Without complications, transfer to the floor POD #1 (uncomplicated AAA or ABF) to POD #5-7 (TAAA)

11. Postoperative Care-Open • Vital Signs every 8 hours • Neurovascular Checks every 8 hours-this includes all pulses. Note this population has high risk for decreased pulses or limb failure. Contact the team with any changes • I and O Record every 8 hours

12. Postoperative Care-Open • Out of the Bed Post op Day #2 • Ambulate in the Hallway TID Post op Day #3 • Physical Therapy Consult- Nursing should walk patient if safe to ambulate • PT will make recs regarding home care and placement, many will need inpatient rehab • Aggressive Pulmonary Toliet

13. Postoperative Care-Open • Clear liquid diet on POD #4 • NPO is NPO, no ice chips • Advance diet to regular day or evening prior to discharge • Patients often will have decreased appetite for 6-8 weeks

14. Postoperative Care- Open • Mid abdominal Incision with Staples • May have incisions in the groin • Vascular Team will take down dressing on POD # 1 and usually leave open to air • Clean and dry • Staples remain in for 2 weeks post op

15. Open Complications • Wound Complications-need to keep clean and dry. • Acute Renal Failure-incidence can be as high as 40% of the population • Cardiac-All should be on pre op Beta Blockade to be discharged home with same protection • Pulmonary-encourage incentive spirometry • Spinal cord ischemia • Colon ischemia

16. Endovascular Repair of AAA and TAA • EVAR techinque was introduced in the 1990s through clinical trials • Decreased Operative Risk • These repairs are beneficial in that they have decreased LOS and recovery time, are able to treat a higher risk patient and most are back to all normal activities within one month • These devices need to be followed long term and CT’s are obtained at one month, six month, and every year intervals

17. EVAR

18. Thoracic Endovascular Repair

19. Intraoperative-Endovascular • Average OR time is 2 hours • Procedure is done under MAC anesthetic so patients are awake throughout • Estimated Blood Loss is 50-250 cc • Thoracic endografts have lumbar catheters placed for spinal cord protection • Most common complication is difficulty with access

20. Endovascular Graft-Incision Site

21. Postoperative Care Endovascular • Endovascular AAA’s go straight to non monitored regular bed • Endovascular TAA’s with spinal drain go to the ICU until drain can be pulled • Patients arrive on floor awake and usually with minimal pain

22. Postoperative Care Endovascular • Vital signs every 4 hours x 2, then q 8 hours-most will run a fever which is post implant syndrome • Neurovascular checks every 4 hours x 2, then q 8 hours-this includes all pulses. Let team know of any changes • I and O every 8 hours • Clear liquids day of surgery and then advance to regular POD #1 • Out of Bed day of surgery • One dose of Ancef post operatively

23. Postoperative Care-Endovascular • LOS- 1 Day-patients should be ready to go home the morning after surgery. 2 Day LOS if have spinal drain • Patients resume home meds and beta blocker • Follow-up is in one month with CT scan • No restrictions on activity except no driving while on pain meds

24. Endovascular Repair of Aneurysms-Complications • Wound-small incisions in groin are at place that can harbor infection. Must keep clean and dry. Must frequently change dressing if draining • Cardiac-protected by beta blockade pre and postoperatively • Lower extremity ischemia • Urinary Retention

25. Thoracic Outlet Syndrome • 3 Types- Venous, Arterial, Neurogenic • 95% is Neurogenic • Compression in the Thoracic Outlet largely induced from the scalene muscle relationship to the brachial plexus • Goal of operation is to decompress nerves via scalenectomy, lysis of fibrous tissue around nerves, and usually removal of first or cervical rib

26. Thoracic Outlet Syndrome-Post op • Low neck incision • Frequent use of a JP drain • Major post op issue is pain control • Some have paravertebral catheter to infuse local anesthetic that are converted to home pump for pain control • Respiratory complications could suggest pneumothorax or hemothorax

27. Thoracic Outlet Syndrome-Post op • There are no upper extremity restrictions • Discharged with script to begin Physical Therapy in 2 weeks • Follow-up in 4 weeks

28. Barriers to Discharge • Activity Level • Urinary Retention • Pain control • Nausea and Vomiting • Initiation of Coumadin • Wound Complications

29. Barriers to Discharge • Placement of Patient in Inpatient Rehab or SNF • Patient or Family Reluctance • Awaiting Home Health Care • Inadequate Resources • Awaiting Final Recs from Consulting Service

30. Questions