TEVAR: Thoracic Endovascular TEVAR: Thoracic Endovascular

Aortic RepairAortic Repair

Postoperative Nursing CarePostoperative Nursing Care

Leslie Collins APN-CNS, CCRN-CSC, CCNS

CNS Cardiothoracic Surgery

Northwest Community Hospital

Learning ObjectivesLearning Objectives

At the end of this session, the participant will be able to:

OIdentify three conditions that are associated with thoracic aortic disease

OList two indications for thoracic endovascular repair

OName two nursing priorities during the postoperative period

OList three interventions appropriate for the management of a lumbar drain

OIdentify two possible complications post thoracic endovascular aortic repair

Diseases of the Aorta Diseases of the Aorta Vascular Vascular

EmergenciesEmergencies

O Aortic aneurysm were primary cause of 10,597 deaths in 2009 and a contributing cause in 17,215 deaths

O Delayed diagnosis secondary to symptoms mimicking other conditions

O ACS

O CVA

O Anatomy of Aorta

O Ascending

O Arch

O Descending

O Abdominal

NormalNormal AortaAorta

Size in CM

Root 3.5-3.91

Ascending 2.86

Mid

Descending

2.39-2.98

Diaphragmatic 2.40-2.69

Aortic Dissection FactsAortic Dissection Facts

O Results from intimal layer of the aorta that allows blood to flow into the medial layer - false lumen

O Pressure changes in the aorta plays a significant role in the propagation or extension of dissection

O Perfusion of major arteries can be reduced or eliminated with blood flow thru false lumen

O Aortic dissection is defined as acute if it occurred within 2 weeks

O About two-thirds of people with aortic dissection are male

Aortic Dissection EtiologyAortic Dissection Etiology

O Iatrogenic

O Procedures with retrograde catheter insertion

O CPB and aortic cross clamping

O Trauma

O MVC or falls

O Diseases

O Hereditary connective tissue disorders: Marfans or Ehlers-Danlos syndrome affect the medial layer of the aorta

O HTN and atherosclerosis weaken medial layer

Classification Classification DeBakey SystemDeBakey System

O Type I: involve entire

aorta

O Type II: ascending

aorta

O Type III: descending

aorta distal to left SC

artery

Classification: Stanford SystemClassification: Stanford System

O Type A: Involves ascending or proximal aorta (DeBakey Types I and II)

O Significant risk for death

O Aortic regurgitation/pericardial tamponade

O Urgent surgical intervention required

O Type B: Descending aorta or distal aorta (DeBakey Type III)

O Medical management for BP control unless symptoms of ischemia are present

O TEVAR

Aortic Aortic

Dissection Dissection

ClassificationClassification

Complications Complications

of Aortic of Aortic

DissectionsDissections

Signs and SymptomsSigns and Symptoms

Location Impairment/Problem Symptoms

Ascending Aorta Damage to aortic valve

Impaired coronary blood flow

Cardiac Tamponade

Laryngeal Nerve Compression

Bleeding into pleural space

Diastolic murmur

Chest pain

Muffled heart tones, JVD, BP,

pulsus paradoxus

Hoarseness

Dyspnea, hemothorax

Aortic Arch blood flow to brain

Interruption of cervical

sympathetic ganglia

Impaired brachialcephalic flow

Syncope, altered MS

Ptosis, miosis, anhidrosis

BP differential, asymmetric

pulses in UE

Descending Aorta Spinal cord ischemia

Mesenteric artery ischemia

Limb paresthesia or paralysis

Acute abdominal pain, melena,

hyper BS

Thoraocabdominal aorta Renal artery ischemia

Lower limb ischemia

Flank pain, oliguria

Diminished or absent pulses in

LE

Indications for Aortic SurgeryIndications for Aortic SurgeryAscending Aorta/Arch Symptomatic or rapidly expanding aneurysm

Aneurysm > 5.5 cm

Aneurysm > 4-5 cm if AI or AS present

All acute Type A dissections

Descending thoracic Symptomatic or rapidly expanding aneurysm

Aneurysm > 6.5 cm

Complicated acute Type B dissections

Thoracoabdominal Symptomatic or rapidly expanding aneurysm

Aneurysm > 5.5-6.0 cm

Abdominal Symptomatic or rapidly expanding aneurysm

Aneurysm > 5.5 cm in low risk patients

Aneurysm > 4.5-5.0 cm in women

Aortic Endovascular GraftsAortic Endovascular Grafts

The Endovascular graft is

intended to exclude the

aneurysm/dissection by

placing the graft inside the

diseased aorta to make a

new path for blood flow

TEVAR: TEVAR: Thoracic Endovascular Aortic RepairThoracic Endovascular Aortic Repair

O Indications

O Descending Thoracic

Aneurysm

O Acute and Chronic Type B

Aortic Dissection

O Mortality for open repair is

high!!

O Goal for repair of dissection:

re-expand true lumen to

ensure flow to vital organs

and false lumen to resolve

Timing of RepairTiming of Repair

Type B DissectionType B DissectionO If repair 3-5 days after dissection

significant risk of re-dissection due to

friable tissue

O If repair > 9 days, then the true lumen may

not re-expand

O Best time frame 8-9 days. Decreased risk

of complications

Preop EvaluationPreop Evaluation

O CTA of chest, abdomen and pelvis with 3-dimensional formatting

O Provides accurate information regarding the external and endoluminal diameter of aorta at the proximal and distal seal zones landing zones

O Evaluate the length of aorta that needs to be repaired

O Identify branches off aorta that may be involved

O Evaluate external iliac artery morphology

O Evaluation for co-morbidities: Cardiac, renal and pulmonary

O CPB standby in case open conversion required

Hybrid ProceduresHybrid Procedures

O Combines standard

operative approaches and

endografts and/or conduit

creation/debranching

O Debranching: the

transposition of the origin

of critical branch vessels

to facilitate a seal zone.

Utilized when arch

arteries at risk for

occlusion with endograft

Postoperative Postoperative

Care of PatientsCare of Patients

Goal of Care

Ensure adequate tissue

perfusion to prevent

ischemia

ComplicationsComplications

O Endoleaks: Aneurysm sac remains pressurized

O Extremity Ischemia

O Renal Failure

O Bowel Ischemia

O Abdominal Compartment Syndrome

O Spinal Cord Ischemia

O Stroke

O Metabolic Acidosis

O Respiratory Complications

EndoleaksEndoleaks

O Defined as persistent

flow of blood into the

aneurysmal sac after

device placement

O Associated with a

continued risk for

aneurysm expansion

or rupture due to

persistent pressure

Classification Classification

of Endoleaksof Endoleaks

Type I EndoleakType I Endoleak

O Due to an incompetent seal at the proximal or

distal attachment sites

O Repaired as soon as they are discovered

O Spontaneous closure is uncommon

O Typically treated with addition of

endograft extensions

Type II EndoleakType II Endoleak

O Due to a patent inferior mesenteric or patent lumbar artery branches that allow retrograde flow into the aneurysm sac abdominal aortic repair

O Spontaneous resolution occurs in many cases.

O Require careful follow up imaging

O An increase of 5-10mm or

persistent endoleak (> 6 months)

are indications for repair

Type III EndoleakType III Endoleak

O Due to a junctional leak or disconnect on the

endograft components, holes in fabric

O Results in pressurized aneurysm sac with

increase risk of rupture

O Treated with deploying additional

stent graft components to seal

defect

Type IV EndoleakType IV Endoleak

O Associated with graft porosity and is self

limited

O Usually resolve in 24 hours

O Can obscure type I and type III leaks

Type V EndoleakType V Endoleak

O Referred to as endotension

O Endotension is defined as continued expansion of the

aneurysm sac greater than 5mm, without evidence of a

leak site.

O It is a poorly understood phenomenon

but thought to be formation of a

transudate due to ultrafiltration of

blood by the graft membrane or

unidentified leak.

TEVAR: Spinal Cord IschemiaTEVAR: Spinal Cord Ischemia

O Paralysis occurs in about

3-6% of all repairs of the

descending aorta due to

interference of the blood

supply to the spinal cord

O May occur immediately

postop from 1-21 days.

Prevention Prevention

and and

Management Management

of Spinal Cord of Spinal Cord

IschemiaIschemia

Spinal Cord IschemiaSpinal Cord Ischemia

O Leads to cord edema and can cause the lumbar ICP to rise and impede normal flow of CSF within the spinal canal and blood flow to the spinal cord

O Mechanism of Injury: The interruption of multiple branch vessels that provide spinal cord perfusion.

O Increase risk

O Complicated Type B Dissections

O Hybrid Aortic Procedures

O Aortic Transection

O Chronic Renal Failure

O Smoking

O Prevent hypotension. Keep MAP > 70-90 mmHg

Spinal Cord IschemiaSpinal Cord Ischemia

O Spinal cord is like the

brain:

O No room for

anything but the

cord, CSF and blood

O Unyielding to

increased spinal

pressures

Lumbar DrainLumbar Drain

O Goal: Patient will remain neurologically intact with no evidence of spinal cord ischemia

O Utilized to minimize risk of spinal cord ischemia by promoting spinal cord blood flow by controlling cerebrospinal fluid pressure

O SCPP: Spinal Cord Perfusion Pressure (>70 mm Hg)

O CSFP: Cerebrospinal Fluid Pressure

SCPP = MAP - CSFP

Medtronic Medtronic

Duet External Duet External

Drainage and Drainage and

Monitoring Monitoring

SystemSystem

Nursing Care of Patient with Nursing Care of Patient with

Lumbar DrainLumbar DrainO Assessment

O Neurologic status

O Obtain baseline assessment

O Subsequent assessments focus on signs of spinal

cord ischemia and/or meningeal irritation

O Signs of infection

O CSF drainage: Amount, color, clarity

O Integrity, function and position of EVD

O Catheter site q 4 hours

Nursing Care of Patient with Nursing Care of Patient with

Lumbar DrainLumbar DrainO External Ventricular Drain Care

O Maintain aseptic technique

O Zero pressure transducer to atmospheric pressure when patient arrives to ICU

O Level drainage system to phlebostatic axis

O Set drip chamber to desired pressure level (typically set at 0)

O Ensure stopcock on transducer is off to drip chamber allows for continuous CSFP monitoring

Nursing Care of Patient with Nursing Care of Patient with

Lumbar DrainLumbar DrainO Activity

O Maintain bedrest to prevent dislodgement of

catheter

O HOB may be elevated for patient comfort

O Re-level transducer with each position change

O Ensure that system is clamped during any

position change

Nursing Care of Patient with Nursing Care of Patient with

Lumbar DrainLumbar DrainO Safety Concerns

O Do NOT flush catheter

O Maintain bed in locked position so patient/family cannot adjust HOB

O Ensure drip chamber is set at level ordered by MD

O Ensure that stopcocks are set so that patient is NOT continuously draining

O Re-level transducer with each position change

O Reposition patient ONLY when catheter is clamped

O No anticoagulants when drain in place. SCDs for DVT prophylaxis

Management of CSFPManagement of CSFP

O Therapy is directed at maintaining a

cerebrospinal fluid pressure (CSFP) between

10-15 mmHg and a MAP between 70 - 90

O If CSFP is > 15 mmHg, may result in decreased

blood flow and perfusion to the spinal cord

Management of CSFPManagement of CSFP

O Therapeutic measures

O Increased CSFP drain CSF. No more than 10ml/hr. Call MD if CSFP remains elevated after drainage

O Increased MAP vasodilator

O Decreased MAP fluids and/or vasopressors

Monitor for signs of spinal cord ischemia and notify surgeon if patient develops changes in motor/sensory function!!

Treatment of Spinal Cord Treatment of Spinal Cord

IschemiaIschemiaO Goal MAP 90-99 mmHg

O Fluid

O Vasopressors

O Drain CSF to obtain CSFP < 10 mmHg

O Frequent neuro assessments to monitor for

resolution of symptoms

Complications of CSF DrainageComplications of CSF Drainage

O Infection

O Overdrainage

O Subdural hematoma

O Herniation

O Spinal Cord Hematoma

O Headache

O Pneumocranium from air entering system

PREVENTION IS KEY!!PREVENTION IS KEY!!

Lumbar Drain RemovalLumbar Drain Removal

O Removal of Drain by anesthesia

O Typically 48-72 hours after procedure

O Clamped for 24 hours prior to removal

O Monitor for S&S of spinal cord ischemia

O Sterile, occlusive dressing applied to site

O Patient to lay flat for 4 hours after removal

O Monitor patient for signs of headache

O Notify anesthesia if patient develops HA or

drainage from drain site

ComplicationsComplications

O Extremity Ischemia

O Due to thrombosis of graft or groin hematoma at insertion site

O Renal Failure

O Due to occlusion of renal arteries by graft (abdominal)

O Due to contrast induced nephropathy

O Bowel Ischemia

O Mesenteric artery occlusion/hypoperfusion (abdominal)

O Paralytic ileus

ComplicationsComplications

O Abdominal Compartment Syndrome

O Secondary to bowel ischemia

O Stroke

O 4-7% risk secondary to diseased aorta

O Metabolic Acidosis

O Hypoperfusion somewhere

O Respiratory Complications

O Prolonged bedrest with lumbar drain

Discharge and FollowDischarge and Follow--upup

O Typically discharged 1-2 days after drain

removal

O Ambulating

O Pain controlled

O CT scan at 1, 2, 6 and 12 months and then

annually to assess for aortic growth

Discharge InstructionsDischarge Instructions

O Activity

O No heavy lifting or strenuous activity for 2 weeks after surgery

O Increase in intra-thoracic pressure resulting in dramatic increase in systemic arterial pressure (300 mmHg)

O No driving for minimum of 1 week

O Diet: Resume preop diet

O Medications: Beta-blocker!!

O Shower: May shower on POD#3. No tub baths until cleared by surgeon

ReferencesReferences

O Fedorow, C. A., Moon, M.C., Mutch, A. C., Grocott, H. P., LumbarCerebrospinal Fluid Drainage for Thoracoabdominal Aortic surgery: Rationale and Practical Considerations for Management. Anesthesia & Analgesia, 2010, 111(1), 46-57.

O Littlejohns, L. Bader, M. (Ed.) AACN-AANN Protocols for Practice: Monitoring Technologies for Critically Ill Neuroscience Patients (2009). Jones & Bartlett Publishers; Sudbury, MA.

O Mehta, M., Hnath, J.C., Sternbach, Y., Taggert, J.B., Kreienberg, P.B., Spirig, A., Roddy, S.P., Paty, P.S.K., Ozsvath, K., Chang, B., Darling III, R.C., and Shah, D. Cerebrospinal Fluid Drainage During TEVAR. Endovascular Today, 2008, 44-46.

O Svensson, L.G., Kouchoukos, N. T., Miller C., et al. Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts. Ann Thorac Surg 2008: 85:S1-41.

O Thompson, H. J. (ed). AANN Clinical Practice Guidelines Series: Care of the Patient Undergoing Intracranial Pressure Monitoring/External Ventricular Drainage or Lumbar Drainage. (2011). From www.aann.org.

Questions???Questions???