Arterial blood vessel disorders Flashcards
(88 cards)
1
Q
what is the most common cause of PAD
A
artherosclerosis (in adults >40)
2
Q
other causes of PAD
A
thrombosis embolism vasculitis (giant cell and Takayasu's arteritis) fibromuscular dysplasia entrapment (thoracic oulet syndrome) trauma
3
Q
highest prevalence in what decades of life for PAD
A
6th or 7th
4
Q
increased risk of PAD
A
smoker
DM
hypercholesterolemia
HTN
5
Q
which type of vessels does atherosclerotic PAD occur
A
localized to large and medium sized vessels
-typically occur at branch sites of vessels
6
Q
-primary sites of involvement for atherosclerotic PAD
A
- femoral and popliteal arteries - MC**
- abdominal aorta and iliac arteries
- more distal vessels (tibial and peroneal artereis)
7
Q
atherosclerotic PAD presentation
A
8
Q
what is claudication in atherosclerotic PAD
A
pain, ache, cramp, numbness or a sense of fatigue in the muscles that occurs during exercise and is relieved with rest (intermittent claudication)
- site of claudication is always distal to the site of the lesion
- symptoms develop at different distances depending on the degree of occlusion and stenosis
9
Q
general PE findings for atherosclerotic PAD
A
- decreased or absent pulses distal to the obstruction
- presence of bruit over the narrowed artery
- muscle atrophy distal from the site of lesion
10
Q
PE findings in severe atherosclerotic PAD
A
- hair loss
- thickened nails
- smooth and shiny skin
- reduced skin temp
- pallor to skin
11
Q
most common site of dz in atherosclerotic PAD
A
- aortoiliac
- femoral/popliteal
- lower leg/foot
12
Q
atherosclerotic PAD - aortoiliac artery dz
- where does claudication occur
- what other complications can occur?
- what pulse changes would be present?
- what other signs would be present?
- ABI results?
A
- claudication occurs in the calves, thighs, and/or buttocks
- erectile dysfunction may occur if b/l dz present
- femoral pulses and distal pulses are absent or weak
- bruit may be heard over the aorta, iliac or femoral arteries or all 3
- ABI will be decreased throut the entire lower extremity
13
Q
atherosclerotic PAD - femoral/popliteal artery dz
- what is the main artery occluded?
- symptoms would be where?
- what other signs would be present?
- pulse changes?
A
- superficial femoral artery is MC artery occluded by atherosclerosis**
- symptoms confined to calf
- may see atrophic changes in the lower leg and foot
- femoral pulse is normal, decreased pulses in popliteal and pedal pulses
14
Q
atherosclerotic PAD - lower leg/foot arterial dz
- involves what vessels
- what is the major risk factor
- pain would be where? relieved?
- type of pain described?
- skin changes?
- pulse changes?
A
- primarily involves tibial vessels
- DM is a major risk factor
- rest pain is confined to dorsum of foot and relieved with dependency
- pain is severe, burning and may awaken pt from sleep
- skin is cool atrophic and hairless
- pedal pulses are absent
15
Q
diagnostic testing for atherosclerotic PAD - noninvasive
A
- ABI
- treadmill testing
- doppler u/s
- MRA
16
Q
what is the ABI
A
- ankle:brachial index
- measure the SBP in the legs and compare it to the arms
- arms and legs should be either equal or ankle>brachial therefore ABI should be >=1.0 in normal individuals
- in the presence of stenosis, SBP in the legs is decreased
- performed with doppler u/s to look at the wave form analysis following a low ABI: shows blunting of the waveform in the presence of PAD
17
Q
what would the ABI be in the presence of stenosis and in the presence of severe stenosis
A
ABI
18
Q
what is treadmill testing for atherosclerotic PAD
A
assess true claudication with exercise (compare resting with exercise)
-decline of ABI immediately after exercise provides further support for the diagnosis of PAD
19
Q
what is duplex doppler u/s
A
- produces an image of the vessel (anatomy) and the surrounding tissue
- able to assess the speed and direction of blood flow thru a vessel
- mostly useful in medium sized and superificial arteries, not for distal small ones
20
Q
management goals for all PAD
A
- improve ability to walk/symptoms
2. prevent progression –>limb ischemia and amputation
21
Q
conservative tx for all pts with PAD
A
- SMOKING CESSATION*
2. risk factor reduction - control BP in HTN pts (ACE-I), lower cholesterol with a statin goal ( LDL
22
Q
foot care for PAD
A
- keep clean and protected against excessive drying
- well fitted and protective shoes to reduce trauma
- avoid support hose/compressive stockings - reduces blood flow to the skin
23
Q
tx of aortoiliac artery dz
A
- conservative
- endovascular surgery: angioplasty/stenting (when segmental or single stenosis)
- surgery (bypass grafting)
24
Q
when is surgery recommended in aortoiliac artery dz
A
progressive reduction in walking distance
limiting ADLs
25
tx of femoral/popliteal artery dz
- conservative
- surgery - bypass most common - mandatory if rest pain or threatened tissue
- angioplasy +/- stenting
- thromboendarterectomy - limited to common femoral artery dz
26
when is surgery recommended for femoral/popliteal artery dz
progressive symptoms, short distance claudication, rest pain or if any ulcerations are present
27
tx of lower leg/foot arterial dz
-conservative
-surgery - required if rest pain at night with low ABI/ monophasic wave forms to prevent tissue loss
(bypass - primary technique to preserve limb)
(amputation - necrotic or severely infected tissue)
28
when is surgery recommended in lower leg/foot arterial dz
if pedal pulses are even slightly weak/reduced and if any uclers are present (regardless of size)
29
prognosis of atherosclerotic PAD
- 15-30% 5 year mortality rate
- 2to6 fold increaed risk of death from coronary heart dz
- worse prognosis if pt continues to smoke or has underlying DM
30
what is fibromuscular dysplasia
- hyperplastic disorder
- results in stenosis and aneurysms of medium and small sized arteries: HTN, dissections, claudication and rest pain if limb vessels are involved
- most commonly involves the renal and carotid arteries
- rare cause of renal artery stenosis
- can also affect blood vessels in extremities
- predominatnly in females (30-40s)
31
s/s of fibromuscular dysplasia
similar to those for atherosclerosis when limb vessels are involved (claudication and rest pain)
-HTN if renal artery is involved
32
dx of fibromuscular dysplasia
renal angiography by a string of bead appearance
33
tx of fibromuscular dysplasia
similar to PAD when limb vessels are involved
| -if renal artery stenosis surgery is curative
34
what is thromboangitis obliterans
aka Buerger's dz
-inflammatory occlusive vascular d/o involving small and medium sized arteries and veins in the distal upper and lower extremities
35
what gender, race, and age is most affected by thromboangitis obliterans
men >40s
asians
and eastern european
36
cause of thromboangitis obliterans
unknown
37
s/s of thromboangitis obliterans
1. claudication of affected extremity
2. Raynaud's phenomenon
3. migratory superficial vein thrombophlebitis
(triad)
38
where is the claudication in thromboangitis obliterans
calves/feet and forearms/hands
| -if severe digital ischemia is present
39
pulses in thromboangitis obliterans
reduced or absent radial, ulanr and or tibial pusles
40
dx of thromboangitis obliterans
bx of involved vessel
41
tx for thromboangitis obliterans
no specific tx except smoking cessation
| -arterial bypass of most proximal affected if possible, local debridement and amputation if required
42
what is Takayasu's arteritis
inflammatory and stenotic dz of medium and large sized arteries
43
Takayasu's arteritis commonly affects what vessels
aortic arch and its branches and subclavian artery
44
prevalence of Takayasu's arteritis
| -what populations affected
rare
| most prevalent in adolescent girls and young women (
45
s/s of Takayasu's arteritis
1. generalized - malaise, fever, night sweats, arthralgias, anorexia, and wt loss
2. vascular symptoms: claudication, decreased/absent pulses, HTN is present in 32-93% of pts, bruits, BP different in B/l arms (>10mmHg)
46
dx of Takayasu's arteritis
arteriography - confirms dx
47
tx of Takayasu's arteritis
glucocorticoid therapy may relieve acute generalized symptoms, but does not treat the condition
-surgery - to decrease the mortatlity rate
48
arterial blood vessel disorders - nonatherosclerotic vascular dz
1. fibromuscular dysplasia
2. thromboangitis obliterans
3. Takayasu's arteritis
49
what is acute arterial occlusion of a limb
sudden loss of blood flow to an exremity
50
size/extent of occlusion and development of collateral blood flow determines what?
1. s/s
2. degree of ischemia
3. viability of the extremity
51
2 causes of acute arterial occlusion of a limb
1. embolism - most common sources: heart, aorta, and large arteries; A fib most common cause
2. primary thrombosis - pts usually have a hx of claudication and now have an acute occlusion
52
clinical features of acute arterial occlusion of a limb
6 P's
1. sudden onset of pain
2. pallor
3. pulselessness
4. paresthesias
5. Poikilothermia (coolness)
6. paralysis
53
if there is adequate collateral circulation (gradual onset) in acute arterial occlusion of a limb what happens to s/s
symptoms may be less impressive
54
acute arterial occlusion of a limb dx
1. clinical
2. doppler u/s to assess blood flow - little or none
3. imaging (MRA
55
tx of acute arterial occlusion of a limb
if limb in jeopardy - immediate revascularization within 3 hours
if limb is not in jeopardy - conservative tx
56
what is conservative tx in acute arterial occlusion of a limb
prevents recurrent embolism and reduce the likelihood of clot propagation
57
prognosis of acute arterial occlusion of a limb
10-25% risk of amputation with acute arterial occlusion form emboli
prognosis for acute thrombotic occlusion is better d/t collateral flow
58
what is thoracic outlet compression syndrome
compression of neurovascular bundle (artery vein nerve) at the thoracic outlet as it courses thru the neck/shoulder
59
causes of thoracic outlet compression syndrome
1. cervical ribs
2. abnormalities of muscles or their insertion
3. proximity of clavicle to the first rib
60
s/s of thoracic outlet compression syndrome
1. combo of 4 symptoms in upper extremity
| - pain, numbness, weakness and swelling (depends on structures being compressed)
61
arterial vs venous s/s of thoracic outlet compression syndrome
2. vascular:
- arterial ischemia - pallor of fingers on elevation of the extremity, sensitivity to cold and rarely gangrene of the digits
- venous obstruction - edema, cyanosis and engorgement
62
symptoms can be brought on how in thoracic outlet compression syndrome
1. wright's manuever
| 2. adson's test
63
what is the wright's maneuver for thoracic outlet compression syndrome
radial pulse weakens or disappears when the arm is abducted and externally rotated on affect side
-hyperabduction test
64
what is Adson's test in thoracic outlet compression syndrome
radial pulse weakens or disappears when the patient rotates their head to the affected side with extended neck following deep inspiration
65
ddx of thoracic outlet compression syndrome
OA of the spine
tumors of the lung, spinal cord or nerve roots
peri arthritis of the shoulder
66
dx of thoracic outlet compression syndrome
CXR - IDs cervical rib
MRI - w/ arm held in a certain position
Angiography - arterial/venous obstruction
67
tx of thoracic outlet compression syndrome
```
95% treated successfully with conservative tx
-PT and avoiding aggravating positions/activities
operative tx (
```
68
peripheral artery aneurysm
- most common artery?
- can it recur?
- most common presentation?
popliteal artery aneurysms are the most common (70%)
- 50% b/l
- tend to embolize repetitively over time and occlude arteries
- most common presentation is limb ischemia secondary to thrombosis or embolism
69
peripheral artery aneurysm
| -clinical findings
1. femoral - may feel a pulsatile mass in groin
2. popliteal - often undetected
- first symptoms may be d/t ischemia
- range from sudden onset pain and paralysis to short distance claudication that slowly lessens as collateral flow develops
- recurrent pain in the foot with cyanosis suggests emobolization and requires a thorough work up
70
imaging for peripheral artery aneurysm
duplex u/s - gold standard
| MRA/CTA - required for reconstruction/surgery
71
tx for peripheral artery aneurysm
- 1/3 of pts require amputation
| - indications for surgery - if symptomatic, >2cm in diameter or if a thrombus is present within the aneurysms
72
what is Raynaud's Phenomenon
syndrome of paroxysmal digital ischemia
73
most common cause of Raynaud's Phenomenon
exaggerated vasoconstriction of distal arteries in response to cold or emotional stress
74
Raynaud's Phenomenon primarily affects
fingers but can affect toes
75
2 phases of Raynaud's Phenomenon
1. initial phase - excessive vasoconstriction: digital pallor or cyanosis
2. recovery phase - vasodilation: intense hyperemia (increased blood flow) and rubor
76
s/s of raynaud's by phase
1. initial phase: fingers turn white when exposed to cold and become painful
2. recovery phase: intense rubor, throbbing, parethesisas, pain and slight swelling
- resolves with rewarming of extremities
77
2 types of Raynaud's Phenomenon
1. primary - idiopathic or raynaud's
| 2. secondary
78
primary Raynaud's Phenomenon
2-6% of adults
more common in young women
appears first bw ages 15-30yo
symmetric involvement is the rule
79
secondary Raynaud's Phenomenon
rare
associated with rheumatic dz
causes digital pitting, ulceration and or gangrene
80
definition of PAD
disorder where there is a stenosis or occlusion in the aorta or distal arteries of the limbs
81
tx of primary RP
1. keep extremities war, wear gloves,protect hands fro injury, treat dry skin, smoking cessation, avoid sympathomimetic drugs (decong, diet pills)
2. meds for severe: CCB - first line, alpha adrenergic antagonists
82
tx of secondary RP
general measures as in primary
| treat underlying illness (rheumatology consult)
83
what is acrocyanosis
arterial vasoconstriction and secondary dilation of the capillaries and venules resulting in persistent (not episodic) cyanosis of the hands and occasionally feet
-worse when exposed to the cold
84
primary acrocyanosis
- population affected
- s/s
- tx
women>men
85
what is pernio
chilbains
| -vasculitis d/o associated with exposure to cold
86
population of pernio
-most commonly occurs in young women, but may occur in adults and children
87
s/s of pernio
- raised erythematous lesions develop on the distal lower extremities in cold weather
- pain, pruritis and/or burning
- may ulcerate and blister
88
tx of pernio
avoid exposure to cold
wound care over ulcers
sympatholytic agents and dihydropydidine CCB may be effective
-usually self limiting
