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 cc
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 Colon ischemia
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 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