Care of the Vascular Patient

Stacey Becker, RNAngela Allen, ACNP

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

Primary Procedures-Open

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

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

Aneurysm Classification

Infra-renal AAA

Juxta-renal AAA

Supra-renal AAA

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

Open AAA Repair

Transperitoneal

Retroperitoneal

Aortobifemoral Bypass

TAAA Open Repair

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)

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

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

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

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

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

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

EVAR

Thoracic Endovascular Repair

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

Endovascular Graft-Incision Site

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

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

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

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

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

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

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

Barriers to Discharge

• Activity Level• Urinary Retention• Pain control• Nausea and Vomiting• Initiation of Coumadin• Wound Complications

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

Questions