Focus on Disorders of the Aorta

(Relates to Chapter 38, Nursing Management: Vascular Disorders, in the textbook)

Learning Outcomes

Safe and Effective Care Environment

4/7/2014

Collaborate with interdisciplinary healthcare team members when providing

care for patients with vascular problems

Health Promotion and Maintenance

Identify risk factors for vascular problems

Teach patients about lifestyle modifications to prevent vascular problems

Learning Outcomes

Physiologic Integrity

Monitor for complications of vascular surgery

Perform a focused vascular assessment

Disorders of the Aorta

Most common vascular problems of aorta

Aneurysms

Aortoiliac occlusive disease (like PAD)

Aortic dissection

Aorta

Largest artery

Responsible for supplying oxygenated blood to essentially all vital organs

Aortic Aneurysms Definition: something happens to the arterial wall

Outpunchings or dilations of the arterial wall

Common problems involving aorta

Occur in men more often than in women

Incidence with age

See gender Differences, p. 867

Abdominal aortic aneurysms (AAA) (you can have multiple aneurysms!)

Occur in 4.1% to 14.2% of men

0.35% to 6.2% of women over 60 years of age

Cause of 16,000 deaths per year

In Canada, account for 0.7% of all mortalities

Aortic Aneurysms Etiology and Pathophysiology

May involve the aortic arch, thoracic aorta, and/or abdominal aorta

Most are found in abdominal aorta below renal arteries

of true aortic aneurysms occur in abdominal aorta

found in thoracic

May have aneurysm in more than one location

Growth rate unpredictable

Larger the aneurysm greater risk of rupture

The bigger it gets is more likely it is to POP (like a balloon) ***

Dilated aortic wall becomes lined with thrombi that can embolize

Leads to acute ischemic symptoms in distal branches

Can cause changes in all extremities*

Causes:

Degenerative: most common**( atherosclerosis)

Congenital:

Familial tendency related to abnormalities*(dont know why)

Ehlers-Danlos syndrome and Marfan syndrome

Mechanical:

Atherosclerotic plaques deposit beneath the intima: DISEASE CAN

HAPPEN ANYWHERE**

Plaque formation is thought to cause degenerative changes in

the media***

Leading to loss of elasticity, weakening, and aortic dilation

Male gender and smoking stronger risk factors than

hypertension and diabetes*****

Inflammatory

Takayasus or giant cell arthritis

Infectious

Penetrating or blunt trauma**

Syphilis, Salmonella, HIV

Most common cause is atherosclerosis****

Studies suggest strong genetic predisposition

Aortic Aneurysms Classification:

2 Basic classifications

True

False (pseudo aneurysm)

True aneurysm:**

Wall of artery forms the aneurysm

At least one vessel layer still intact (outermost layer)**

Further subdivided:

Fusiform (both sides of artery)

Circumferential, relatively uniform in shape

Saccular

Pouch like with narrow neck connecting bulge to one

side of arterial wall

False aneurysm:

Also called pseudo aneurysm

Not an aneurysm***

Disruption of all layers of arterial wall****

Results in bleeding contained by surrounding structures

May result from

Trauma

Infection

After peripheral artery bypass graft surgery at site of

anastomosis (NOT SUTURED CORRECTLY)

Arterial leakage after cannula removal

Thoracic aorta aneurysms: (VERY BAD)***

Often asymptomatic*

Most common manifestation (as aneurysm gets bigger symptoms progress)**

Deep, diffuse chest pain (can mimic angina pain) (1ST sign)

Pain may extend to the interscapular area

Ascending aorta/aortic arch

Produce angina

Hoarseness

If presses on superior vena cava:**

Decreased venous return can cause:

Distended neck veins

Edema of head and arms

SUPERIOR VENA CAVA SYNDROME**

Abdominal aortic aneurysms (AAA) (PATIENT FEELS FINE) **

Often asymptomatic

Frequently detected:

On physical exam:

Pulsatile mass in per umbilical area

Bruit may be auscultated

When patient examined for unrelated problem (i.e., CT scan,

abdominal x-ray)

NORMAL FINDING: PULSATING AROUND THE AORTIC REGION

ON 86 YEAR OLD MAN VERY THIN**
YOU WILL FEEL A MASS INSTEAD OF A PULSATION**

YOU WILL ALSO HEAR BRUIT THROUGH

STETHOSCOPE* (TURBULANCE OF BLOOD GOING
THROUGH DILATED AREA)

KNOW DEEP PALPATION OR IT CAN CAUSE THE

ANEURYSM TO RUPTURE** DO NOT KILL YOUR PT

May mimic pain associated with abdominal or back disorders***

If aneurysm is posterior (pain in back)

If aneurysm is anterior (abdominal pain)

May spontaneously embolize plaque

Causing blue toe syndrome**

Patchy mottling of feet/toes with presence of palpable pedal

pulses**** toes look cyanotic **

Aortic Aneurysm Complications:***

Ruptureserious complication related to untreated aneurysm

Posterior rupture: ( YOU WANT THIS ONE)** a lot of stuff that could by
you more time to get fixed**

Bleeding may be tamponaded by surrounding structures, thus

preventing exsanguination and death***

Severe pain (agonizing back pain)**

May/may not have back/flank ecchymosis **

You will see signs of bleeding**

Anterior rupture: NOT GOOD-MEDICAL-SURGICAL EMERGENCY!!!!****

Massive hemorrhage

Most do not survive long enough to get to the hospital***

Aortic Aneurysm Diagnostic Studies****

X-rays (can show widening of the aorta) (something wrong)**

ChestDemonstrate mediastinal silhouette and any abnormal

widening of thoracic aorta

AbdomenMay show calcification within wall of AAA

ECG to rule out MI (make sure it is not cardiac)**

Echocardiography**

Assists in diagnosis of aortic valve insufficiency

Related to ascending aortic dilation

Ultrasonography (once an aneurysm is diagnosed)**

Useful in screening for aneurysms

Monitor aneurysm size (they keep an eye on it to see if it is

growing)**

Closer to aortic route (prone to aneurysms)**

Pt will come in every 6 months for further evaluation

and growth**

CT scan (most accurate)*****

Most accurate test to determine

Anterior to posterior length

Cross-sectional diameter

Presence of thrombus in aneurysm

MRI

Diagnose and assess the location and severity

Angiography (is not routinely done to dx)**

Anatomic mapping of aortic system using contrast

Not reliable method of determining diameter or length

Can provide accurate info about involvement of intestinal,

renal, or distal vessels****

Aortic Aneurysm Collaborative Care: Table 38-1***

Goalto prevent aneurysm from rupturing

Once detected:(must go for further f/u)** *(they need to do what theyre

supposed to do or else DEATH)**

Early detection/treatment imperative

Studies done to determine size and location

If carotid and/or coronary artery obstructions present

May need to be corrected before repair*

THEY WONT SURVIVE SURGERY IF THEY HAVE CAD****

Small aneurysm (<4 cm) (YOU WILL WATCH IT) (PT WILL GO FOR REGULAR
FOLLOW UPS TO SEE IF IT IS GETTING BIGGER)***

Conservative therapy used: (LIFE STYLE MODIFICATIONS)**

Risk factor modification

Blood pressure****

Ultrasound, MRI, CT scan monitoring q 6 months

YOU MUST GO FOR F/U******

5.5 cm is threshold for repair (men)** ****

Intervention at <5.5 cm in women with AAA

they only perform surgery if it is needed**

No strict criteria (depending on woman)

Surgical intervention may occur earlier in

Younger, low-risk patients (trauma)

Will consider surgery

Rapidly expanding aneurysm

Symptomatic patient* (back pain, abdominal pain)

High rupture risk (if aneurysm is growing fast they will take the pt to
OR before it ruptures)***

Older, high-risk patients: (with co-morbidities)

Endovascular repair may be treatment of choice****

No OR. PT WILL NOT SURVIVE**

Surgical Therapy****

If ruptured, emergent surgical intervention required

33%-94% mortality with ruptured AAAs*** (BAD)

Preop:** (routine pre-op care)**

IV FLUIDS, NPO, BOWEL PREP, SPINTING, COUGHING AND DEEP

BREATHING, INSENSTIVE SPIROMETY, AMBULATION

Hydration

Lab work (make sure pt is not bleeding)** (H&H)

HEMOGLOBIN: 12-15%

HEMATOCRIT: 35-47%

Electrolyte, coagulation, hematocrit stabilized

Make sure you have blood on hand**

Surgical Technique: (38-4)*** (SLICE INTO IT, OPEN UP AND TAKE OUT
PLAQUE, THAN PUT A GRAFT IN)

Incising diseased segment of aorta

Removing intraluminal thrombus or plaque

Inserting synthetic graft

Suturing the native aortic wall around graft

Dacron or polytetrafluoroethylene (PTFE)

Acts as protective cover

Aortic Aneurysm Collaborative Care:****

Auto transfusion reduces need for blood transfusion during surgery**

DONT HAVE TO WORRY ABOUT TRANSFUSION REACTION**

THE BLOOD THAT IS COMING OUT OF PT WILL GO RIGHT BACK

IN***

AAA resections**

Require cross-clamping of aorta proximal and distal to aneurysm

Can be completed in 30-45 minutes

Clamps are removed and blood flow to lower extremities restored**

If extends above renal arteries or if cross clamp must be applied above

renal arteries

Adequate renal perfusion after clamp removal should be

ascertained before closure of incision

Risk of postop renal complications significantly when repair

is above renal arteries*** (KEEP A GOOD WATCH ON PT
KIDNEY STATUS)**

Post op Complications: Aortic Aneurysm **

WILL BE IN ICU** Asses VS/ circulation q15 minutes**, than hourly once they hit
parameters provider wants, Pulses are starting to diminish call provider***, make
sure those pulses are clearly marked** check in the same spot**, change in color of
extremities, if pt is experiencing pain other than incisional pain, make sure you
measure abdominal circumferences, watch URINE OUTPUT** (HOURLY)**

Endovascular graft procedure:****

Alternative to conventional surgical repair****

Involves placement of suture less aortic graft into abdominal aorta

inside aneurysm

Done through femoral artery cut down

Graft:

Constructed from Dacron cylinder

Surface supported with rings of flexible wire

Delivered through sheath to predetermined point

Deployed against vessel wall by balloon inflation

Anchored to vessel by series of small hooks

Blood flows through graft, preventing expansion of aneurysm

Aneurysm wall will begin to shrink over time (shrivels up from

lack of blood)**

Must meet strict eligibility criteria to be candidate

Benefits:***

anesthesia and operative time

Smaller operative blood loss

morbidity and mortality

More rapid resumption of physical activity

Shortened hospital stay

Quicker recovery

Higher patient satisfaction

Reduction in overall costs

Potential complications: (BAD THINGS CAN STILL HAPPEN)**

Aneurysm growth

Aneurysm rupture

Per graft leaks***

Aortic dissection****

Bleeding (BLOOD PRESSURE MUST BE KEPT IN ACCEPTABLE

PARAMETERS)**

Graft dislocation and embolization

Graft thrombosis

Incisional site hematoma

Site infection

Most common complication is per graft leak**

Graft dysfunction may require traditional surgical repair**

Seeping of blood from new endograft into old aneurysm

site

With endovascular repair

Higher reintervention rate

Need for long-term follow up*** (MIGHT NEED TO

HAVE MORE THAN ONE)

Long-term complications not known**

New approach is percutaneous femoral access***

Advantages:

Shorter operative time

Shorter anesthesia time

Reduction in use of general anesthesia

Reduced groin complications within first 6 months

Thoracic Aneurism Collaborative Care: ***

Repair tailored to each patient

Ascending aorta repair requires cardiopulmonary bypass

Partial bypass used for descending thoracic aorta

Care similar to other thoracic surgeries

Review pp. 571-574**

Acute Intervention:

Expectations after surgery: TELL PT WHAT IS GOING TO HAPPEN WHEN THEY

WAKE UP, THEY WILL PROBABLY BE INTUBATED**

Recovery room, tubes, drains, Foleys

ICU

Complications: CALL RAPID RESPONSE!!!**** (if pt is hemorrhaging)***

Assess vital signs more frequently and report changes to HCP**

Hemorrhage**** (look at chest tube drainage!)*****

800ml, low bp, high pulse

Ischemic colitis

Cerebral/spinal cord ischemia

Respiratory distress

Dysrhythmias (almost all of them)*

POST OP INTERVENTIONS**

Maintain graft patency*

Normal blood pressure (prescribed parameters for B/P) (your job to get
them)

CVP or PA pressure monitoring**

Urinary output monitoring (Foley input and output)

Avoid severe hypertension:

Drug therapy may be indicated

Nursing Management Assessment:**

Thorough history and physical exam (Head to toe)*

Watch for signs of cardiac, pulmonary, cerebral, lower extremity vascular

problems***

Establish baseline data to compare postoperatively

Note quality and character of peripheral pulses and neurologic status:

Mark/document pedal pulse sites and any skin lesions on lower

extremities before surgery *** VERY IMPORTANT***

Monitor for indications of rupture***

Diaphoresis

Pallor

Weakness

Tachycardia

Hypotension

Abdominal, back, groin, or per umbilical pain (LISTEN TO YOUR PT)**

Changes in level of consciousness***

Pulsating abdominal mass

Nursing Management Planning:

Multiple IV drugs (IV HYPOTENSIVES MUST BE

TITRATED) **

Overall goals include:

Normal tissue perfusion

Intact motor and sensory function

No complications related to surgical repair

Nursing Management Nursing Implementation:

Health Promotion

Alert for opportunities to teach health promotion to patients and their

families

Teach patients with HTN the importance of taking prescribed drugs

Encourage patient to reduce cardiovascular risk factors

EVEN IF THEY FEEL FINE WATCH CLIENT FAT INTAKE

STOP SMOKING!!**** (ESPECIALLY MEN)**

These measures help ensure graft patency after surgery

Acute Intervention: (Pt has an aneurysm and needs surgery)***

Patient/family teaching

Providing support for patient/family (pt is very anxious)

Careful assessment of all body systems

Pre-op teaching**

Brief explanation of disease process

Planned surgical procedure

Pre-op routines*

Bowel prep (severe abdominal pain notify PCP)

NPO (NG TUBE) (POST OP)**

Shower

Postop **

ICU monitoring

Arterial line (CAN GIVE MEDS THROUGH)**

Central venous pressure (CVP) or pulmonary artery (PA)

catheter

Mechanical ventilation (WILL BE ON MACHINE)**

Urinary catheter (INPUT AND OUTPUT EVERYHOUR)*

Nasogastric tube (A FEW DAYS UNTIL BOWEL SOUNDS

RETURN) (PASSING GAS)*** THAN NG tube can come out

ECG

Pulse oximetry

Pain medication (PCA PUMP)

Cardiovascular status:

Continuous ECG monitoring (assess for dysrhythmias)

Electrolyte monitoring (LIGHTS AND 02)**

Arterial blood gas monitoring (ARTERIAL LINE)

Oxygen administration (ENDOTRACHEAL TUBE, and

then mask, than nasal cannula)

Antidysrhythmic/pain medications

Infection: (PREVENTON)**

Antibiotic administration (PROPHLAXIS)

Assessment of body temperature***

Monitoring of WBC (IV fluids and then advanced fluids)

Adequate nutrition (IV fluids and then advanced fluids

once NG tube comes out** )

Observe surgical incision for signs of infection**

Gastrointestinal status

Nasogastric tube

Abdominal assessment

Passing of flatus is key sign of returning bowel function

Watch for manifestations of bowel ischemia

YOU WILL EXPECT A SLIGHT INCREASE AFTER

SURGERY**

4-5 days no passing of gas theirs a problem***

Peripheral perfusion status:

Extremity assessment

Neurologic status:

Level of consciousness (very important call RAPID

RESPONSE)****

Pupil size and response to light

Facial symmetry

Speech (CRANIAL NERVES)* (OCCUMOTER NERVE)*

Ability to move upper extremities

Quality of hand grasps

Pulse assessment:

Temperature, color, capillary refill time, sensation and

movement of extremities

Mark pulse locations with felt-tipped pen***

Renal perfusion status:

Urinary output

Strict input and output

Every drop must be accounted for**

Fluid intake

Daily weight (watch out for kidneys)**

CVP/PA pressure (fluid retention)**

Blood urea nitrogen/creatinine

Aortic Aneurism: To Review:***

Nursing Implications:

Assess VS/circulation q 15 min, then hourly

Report signs of graft occlusion/rupture (immediately)

Changes in pulses (2+) and now cant find pulse

Cool/cold extremities below graft (color)

White or blue extremities/flank

Severe pain ***

Abdominal distention (pay attention, especially if abdomen

increased in size) **

Decreased urine output **

Thoracic Aneurism: To Review***

Assess VS at least q hour

Assess for significant increase in drainage from chest tubes

Assess for sensation and motion in extremities***

Ambulatory and Home Care:

Encourage patient to express concerns

Patient instructed to gradually increase activities (they need too)

No heavy lifting (watch for restrictions)**

Get someone right away**

Dont pick up grand kid

Stool Softeners (NO STRAINING)**

Educate on signs and symptoms of complications(very important) *

Infection (SPIKE IN TEMP, PRODUCTIVE COUGH)

Neurovascular changes (FEEL GOING NUMB)***

Nursing Management Evaluation:

Expected Outcomes:

Patent arterial graft with adequate distal perfusion

Adequate urine output (KIDNEYS ARE HAPPY THEY MAKE PLENTY OF

URINE)

Normal body temperature

No signs of infection

 Aortic Dissection (Part 2)**

Often misnamed dissecting aneurysm (more like a hematoma)**

Not a type of aneurysm****

Occurs most commonly in thoracic aorta

Result of a tear in the intimal lining of arterial wall

Blood flows into crack and creates a false lumen*

Affects men more often than women

Occurs most frequently between fourth and seventh decades of life

Acute and life threatening **

Mortality rate 90% if not surgically treated*****

Aortic Dissection Etiology and Pathophysiology

Tear in intimal lining allows blood to track between intima and media (collects in
the middle)**

Creates a false lumen of blood flow

As heart contracts, each systolic pulsation pressure on damaged area

Further dissection

May occlude major branches of aorta:

Cutting off blood supply to brain, abdominal organs, kidneys, spinal

cord, and extremities*** (depending on the location) (going into the
false lumen instead of the organs, where it is supposed to go)**

Cause is uncertain

Many attribute to destruction of medial layer elastic fibers

Most people with dissection are older with chronic hypertension

Persons with Marfan syndrome incidence

Blunt trauma can precipitate

 Aortic Dissection Clinical Manifestations:

Depend on location of intimal tear and extent of dissection

Pain characterized as: (sudden onset)***

Sudden, severe pain in anterior part of chest or intrascapular pain radiating

down spine to abdomen or legs

FEELS LIKE SOMETHING TORE INTO HIS CHEST*

Described as tearing or ripping

May mimic that of MI (DO NOT GIVE HEPARIN)***

As dissection progresses, pain may be above and below diaphragm

Cardiovascular, neurologic, and respiratory signs may be present

If aortic arch involved (loss of circulation)**

Where and how large the tear is***

Neurologic deficiencies may be present

Aortic Dissection Complications:

Cardiac tamponade:***

Severe, life-threatening complication***

Occurs when blood escapes from dissection into pericardial sac

Cardiac output takes a nose dive**

Clinical manifestations include: (cardiogenic shock)**

Hypotension (very severe) (70/60) (heart is not moving)

Narrowed pulse pressure

Distended neck veins (JVD) (clear lung sounds)

Muffled heart sounds

VERY FAR AWAY (BLOOD ALL AROUND THE HEART)**

Tachycardia (affects the SA node)

Than bradycardia**

Dyspnea

Fatigue

Pulsus paradoxus*****

TAKE BLOOD PRESSURE TWICE* ASK PT TO BREATHE IN THE B/P WILL

DROP**

Aorta may rupture:

Results in exsanguination and death***

Hemorrhage may occur in mediastinal, pleural, or abdominal cavities

Occlusion of arterial supply to vital organs (AORTA CAN NOT CONTAIN IT

ANYMORE SO IT POPS)**

Aortic Dissection Diagnostic Studies:

Health history and physical exam

ECG (RULE OUT MI)** (WILL BE NORMAL)

CXR (WIDENING OF THORACIC AORTA)

CT scan/MRI (DEFINITIVE DIAGNOSIS)** ***

Trans-esophageal echocardiogram (if pt makes it that far it is useful)**

Left ventricular hypertrophy from systemic hypertension

Chest x-ray

Trans esophageal echocardiogram

May show widening of mediastinal silhouette and left pleural effusion

Identify dissections closest to aortic root

MRI or multi-detector row CT scan*** (gives good visual visualization)

Emergency diagnostic procedures of choice

Provide information on presence and severity of dissection

Angiography

Assess extent of dissection

Aortic Dissection Collaborative Care: Table 38-1

Initial goal (what do you want to do?)

BP and myocardial contractility to diminish pulsatile forces within aorta**

Drug therapy:

IV -adrenergic blocker****

Esmolol (Brevibloc)** (drug of choice)****

Other hypertensive agents:

Calcium channel blockers

Sodium nitroprusside (only if b/p is extremely high and very powerful)

Angiotensin-converting enzyme inhibitors

Fenoldopam (Corlopam) IV

Conservative therapy

If no symptoms

Beta blockers (negative inotropes) (they decrease contractibility)**

Can be treated conservatively for a period of time

Success of the treatment judged by relief of pain

Emergency surgery is needed if involves ascending aorta*****(brain or heart)

Surgical therapy**

When drug therapy is ineffective or when complications of aortic dissection

are present

Heart failure, leaking dissection, occlusion of an artery

Surgery is delayed to allow edema to decrease and permit clotting of blood

Involves resection of aortic segment and replacement with synthetic graft

material

Take out diseased area and graph it into place

Extent of replacement depends on extent of dissection

Even with prompt surgical intervention:

30-day mortality rate of acute aortic dissections remains high (10%28%)

Aortic Dissection: Nursing Management

Pre-op

Semi-Fowlers position** (low puts pressure on aorta)

Maintaining a quiet environment (try to keep noise down and lights low)*

Decrease stimuli***

Anxiety and pain management:

Opioids and tranquilizers as ordered (raises B/P)

GIVE ANIXETY MEDS**

Continuous IV administration of antihypertensive agents

Continuous ECG and intra-arterial pressure monitoring

Observation of changes in quality of peripheral pulses

Frequent vital signs (depending on pt)**

Postop

See aneurysm postop care (discussed earlier)

SAFETY****

Discharge teaching***

Therapeutic regimen

Antihypertensive drugs and side effects

If pain returns or symptoms progress, instruct patient to seek immediate

help!!

EVEN IF YOU FEEL FINE YOU MUST CONTINUE MEDS!!!

ANY CHANGES MUST GO TO HOSPITAL!!*****

Questions:
1. (32:55) Your pt had abdominal aortic surgery repair yesterday urine output is 25ml/hr. and
BUN is 68. What is the priority intervention? Normal: BUN: 8-25mg/dl
a. Assess Vital signs (ALWAYS GET VITAL SIGNS BEFORE YOU CALL PROVIDER)**
b. Increase the IV Fluid rate
c. Continue to assess
d. Call the surgeon immediately