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Flashcards in Blood Vessel and Lymphatic Disorders Deck (69):

A 60 y/o male smoker presents with a 6 month history of impotence along with calf, thigh, and buttocks claudication. The femoralsare not palpable. Angiogram is shown. This man has a (an):

need pic, aorto iliac artery is occluded

aorto-iliac occlusion.


Treatment for artery occlusion

1. Smoking cessation and BP control
2. ASA and/or clopidogrel(Prevents MI, CVA , etc).
3. Cilostazol(Pletal/phosphodiesterase type 3 inhibitor –inhibits platelet aggregation and dilates vessels) 100 mg BID
4. Pentoxifylline(Trental/phosphodiesterase inhibitor with antihemorrheologicactivities) 400 mg TID
5. Ramipril*
6. Statin (rosuvastatin40 mg daily)
7. Stent
8. Axillo-femoral bypass; Aorto-fem bypass
9. Intermittent calf compression. Angiogenesis with injection of mononuclear cells.`


antiplatelet drugs

aspirin thromboxane a2

Cilostazol Pentoxifylline kep 5amp from going to camp


P2Y12 signalling modulates thrombin generation

ADP feedback loop


A 60 y/o diabetic male presents with cramping pain in both calves with walking2-4 blocks. The femoral arterial pulses seem somewhat diminished in the groin, the left popliteal and left pedal pulses are diminished. The right pedal pulses are absent. The Ankle/Brachial index is 0.5 on the left and 0.1 on the right. There is no hair on the right toes and the patient has dependent rubor on the right. The patient most likely has severe occlusion of the

superficial femoral


higher the blockage the sooner you will

have pain


Ankle/Brachial index normal is



If the profunduswere involved, the claudication would

occur much earlier


what artery would be the source of collateral network in pt with superficial femoral blocked



with profundus you could only walk

1-2 blocks


with superficial femoral you can walk

2-4 blocks


under what conditions would it have been possible to have a more normal ABI on the right (ie.8 or .9) and still have poor circulation?

When the vessels are calcified*as in diabetics. This does not allow
practical use of ABI and thus one must resort to wave form analysis.

failed reading with cuff


Osler’s sign or maneuver?

Pseudohypertension because
of calcified vessels.

falsely high


Treatment of superficial and common femoral and popliteal stenosis

•1. structured walking program

•2. Fem-pop bypass*

*absolute indication for surgery –rest pain and non-healing ulceration


A 55 year old man is seen for progressive bilateral leg and calf pain
with ambulation and relief with sitting down in a chair. History is positive for hypertension and the patient is on an ACE inhibitor. Physical examination reveals an S4. Present BP is 130/60. He has a “simian gait” and complains of worse pain with extension of his back and improvement with bending forward. Calves are tender.
Pedal pulses are questionably diminished. Which test will most likely be positive?

lumbar mri

Progressive narrowing of the spinal canal may occur alone or in combination with acute
disc herniations. Lumbar spinal stenosis (LSS) remains the leading preoperative diagnosis
for adults older than 65 years who undergo spine surgery.



atrial kick from unrelaxed ventricle (ventricle is stiff so it makes noise going in)

bc hypertensive heart disease


why are pedal pulses diminished

bc dorsalis pedis may not be where it belongs


spinal stenosis may look like peripheral vascular disease but it gets better when

nerve pain from compression


Lumbar spinal stenosis

Absence of pain or improvement of symptoms when seated assists in ruling in LSS. Patients with significant lumbar spinal canal narrowing report pain, weakness, and numbness in the legs while walking. Compressed nerve roots become ischemic due to stenosis. This is the hallmark of neurogenic claudication. The pain is relieved when the patient flexes the spine by, for example, leaning on shopping carts or sitting. Flexion increases canal size. The most common nerve affected is the L5, with associated weakness of extensor hallucislongus. Neurogenic claudication pain is exacerbated by standing erect and downhill ambulation and is alleviated with sitting, squatting, and lumbar flexion.


Lumbar spinal stenosis Neurogenic claudication pain is exacerbated by

standing erect and downhill ambulation


Lumbar spinal stenosis Neurogenic claudication pain is alleviated with

sitting, squatting, and lumbar flexion.


Tibial and pedal artery occlusion A 45 y/o diabetic presents with burning, dorsal foot pain that is relieved by getting up or dangling the foot. How do you know this is not diabetic neuropathy? How is the diagnosis made? What is the treatment?

relieved by dangling
Vein bypass to distal tibial or pedal arteries. (sometimes vessels cant take the pressure and they rupture when distal)


A 35 y/o male from south Africa presents with sudden onset painin the right lower extremity. The leg is pale, weak, and numb. The pedal pulses are absent and the foot is cold. The heart rhythm is irregular. What has happened?

Acute arterial occlusion of a limb

neuropathy bc no blood is getting down there

arteries feeding nerve are blocked and so you get numb

afib, he has thrown a clot


Acute arterial occlusion of a limb

A. 50% of cardiac emboli go to the legs.

B. With loss of light touch, surgery should be done immediately.

C. Before revascularization, NaHCO3should be administered. (lactic acidosis from hypoxia)

D. Cause is sometimes due to thrombosis.

E. Pedal pulse are not palpable.


6 Ps of acute arterial occlusion

Paresthesias (most concerned about this one)
Poikilothermia* (irregular temp, ice cold)


A 58 y/o hypertensive, diabetic, female presents with dizziness, diploplia, dysphagia, dysarthria, dysmetria, and ataxia of 50 minutes duration. The patient is having which type of an event?

Vertebro-basilar TIA


dizziness, diploplia, dysphagia, dysarthria, dysmetria, and ataxia

The Dsof VB TIAs

brainstem function having to do with these things


The Lateral Medullary Syndrome

with occlusion of vertebral or PICA = the Ds plus numbness in contralateral arm or leg and ipsilateral face, with Horner’s

whalenberg or lateral medullary syndrom


Carotid Territory TIA

Aphasias, unilateral weakness or numbness, and amaurosis fugax (sudden loss of vision in one eye, everything is unilateral)


The Lateral Medullary Syndrome with occlusion
of vertebral or PICA

not asking this...

ringing in the right ear, dizziness and right facial pain. There is nystagmus on right lateral gaze. There is right perceptive deafness. Intention tremor is present on the right with falling to the right with Romberg position. There is loss of pain and temperature over the right face and opposite trunk and extremities with ptosis of the right eye
and constriction of the right pupil..



left you would get expressive or receptive


A 45 y/o hyperlipidemic, diabetic female has had abdominal pain lasting for 2 hours after meals for the past 3 years. She has had a 20 lb weight loss over the past 6 months related to fear of eating. She presents suddenly with periumbilical pain, but no significant clinical abdominal findings except for bloating. The patient has a (an)

mesenteric occlusion

marker for this is palpation and no pain and they are complaining about it


abdomial angina

pain after meals from no blood while trying to digest


mesenteric occlusion treatment

•Angioplasty and stent versus aorto-celiac or superior mesenteric bypass

rt iliac to sma sephanous graft

lt iliac to ima sephanous graft


A 65 y/o female with a history of polycythemia and frequent phlebotomies presents with abdominal pain and swelling. Two months ago she had an episode of amaurosis fugax and two weeks ago, she had left sided numbness that lasted for 10 minutes. She has been having abdominal pain after meals for the past 6 months. Hbis 18 gm with WBC of 13,000 and platelets of 350,000. Exam shows abdominal enlargement with dullness to percussion in the flanks. A CT angiogram is performed and shows portal vein thrombosis. What is most unusual in this patient?

blood clots on both sides and clotting in venous and arterial system

Portal vein thrombosis


Basis of a red clot

venous side

fibrinogen forms and red cells get caught

Caused by multiple thrombophilic* and /or
hypofibrinolytic** factors, mostly inherited. Also
due to acquired risk factors (pregnancy, BCPs,
high dose steroids, immobilization, surgery,
and foreign bodies in the blood stream/catheters


Basis of a white clot

aterial side due to platelet aggregation

Caused by smoking,
hypertension, hyperlipidemia,
DM, cholesterol emboli.


What causes arterial and venous clotting?

said wont be on test

Heparin induced thrombocytopenia (HIT)

Paroxysmal Nocturnal Hemoglobinuria(PNH)

Myeloproliferative disease (especially JAK 2)

Anti Phospholipid Antibody Syndrome (APLAS)

Anti Cardiolipin Antibody Syndrome (ACLA)


Thromboangitis obliterans (Buerger’sdisease: vasculitis of arteries and veins).

Nephrotic syndrome (antithrombinIII, protein S and C deficiency).

Right to left shunt

Popliteal artery aneurysm


Aortic Aneurysms

•USPFTS: One time screening (for AAA) of 65-75 y/o males who have ever smoked. Insufficient evidence for women.

•Truly significant at 5-6 cm. (when you ahve to operate)

•Thrombosis in aortic aneurysms -no anticoagulation

•Do coronary surgery prior to aneurysm repair.


What is the treatment for an aortic aneurysm?

•Labetolol20 mg over 2 min IV (want to drop bp), then 40 -80 mg q 10 min

•Esmolol0.5 mg/kg IV

•Nitroprusside50 mg in 1000 D5 at 0.5 mL/min

•Surgical repair or endovascular graft (older pts)


A tall, thin 35 y/o male presents for a flight physical to renew his license for Delta. During the exam he is found to have a 3/6 diastolic decresendo murmur at the base, with a 2/6 systolic murmur at the apex that lengthens with standing and shortens with handgrip. History is positive for a prior pneumothorax. Which would be an additional finding in this patient?

on the test

problem with collagen tissue so proglem at valve rings

Aortic root dilation

as it dialated it went down to the ring


diastolic decresendo murmur at the base

aortic insufficiency


systolic murmur at the apex that lengthens with standing and shortens with handgrip

mitral regurg


Which is associated with a dissecting aortic aneurysm?

dissection into the intima

sharp intense chest pain

inferior wall mi

diastolic murmur



gets close to right coronary artery and you get an infaction in the inferior wall

4-5 % of people have arteries going to spinal cord so you get paraplegia


Can also see dissection in

pregnancy, bicuspid aortic valve, and coarctation.


Know the symptoms of a dissecting ascending thoracic aortic aneurysm
versus a descending thoracic aortic aneurysm as given in Lange’s CMDT!

open langs


What is the medical treatment for an expanding or dissecting aortic aneurysm?



What produces mediastinal widening?

not on test

•Artifact –patient rotated

•Mediastinal Mass –T and B cell lymphoma, teratoma, thyroid, thymus = 4 Ts

•Vessels –aortic aneurysm



Peripheral Artery Aneurysms

•An easily palpable popliteal pulse may well be an aneurysm which can present with loss of distal pulse with acute leg or foot pain

•Popliteal aneurysms account for 70% of peripheral arterial aneurysms –risk include thrombosis and embolization.

•In treatment, surgery is indicated for peripheral embolization, > 2cm or a mural thrombus. Often can be conservative if light touch remains in tact


Which of the following predisposes to thrombophlebitis?



Virchow’s Triad

Hypercoagulability (lack of fibrinolysis protein cs and antithrombin deficiencies)


This patient had presented with a post-phlebiticsyndrome involving the left leg. The clot in the left iliac vein was related to pressure from the

right iliac

right iliac artery is crossing over left iliac vein, sets up clots in people

iliac clot occurs on the left side, called may ferners syndrome

May –Thurnersyndrome: may account for 30%
of all venous events in the US each year.


A 59 y/o male with pancreatic cancer presents with a two week history of a swollen left leg with calf tenderness. Physical exam shows a superficial phlebitis of the left arm. The cause of these findings is most likely:

systemic hypercoagulability.

Trousseau’s syndrome


Trousseau’s syndrome

Armand Trousseau who diagnosed himself with gastric cancer. Involves mucin(glycans) producing epithelial cancers that activate platelet and leukocyte (P and L) selectins(CD62/glycoproteins or cell adhesion molecules/CAMs) that lead to platelet rich microthrombi(seen most often in adenocarcinoma of the lung).
Thrombogenic cancers: gastric, esophageal, lung, pancreas, renal, ovarian, AML, non-Hodgkins lymphoma*.

adenocarcinomas you activate and l selectins so they get more sticky and you get a clot


Venous Ulcers

need to know this

History of trauma, pregnancy, and varicose veins

Medial malleolus

Superficial, irregular margins

Ruddy, beefy (bc artery is good), fibrinous, granulation



Lipodermatosclerosi –indurated

Hyperpigmentation -hemosiderin

Moderate to heavy exudate
Cap refilling -


Arterial ulcers

need to know

History of smoking, rest pain claudication

Site of pressure

Deep, “punched out” with sharp borders

Bed pale grey or yellow

Dry necrotic base with eschar

Pale,hair loss, cold feet, atrophic skin, no pulses

Cap filling >4-5 sec.

Elevation pallor


Neuropathic ulcer*

History of numbness

Common in DM

Pressure site

Variable depth

Surrounding callus

Cap refilling normal

ABI = normal

firm ridge and callous around it


Chronic leg ulcers


Venous insufficiency


Autoimmune diseases (Felty’s)

SS anemia



Infection (fungal)

Hypertension (Martorell’s)


Septic Superficial Thrombophlebitis

don't worry about

•Vancomycin15 mg/kg IV q 12 hrs
•Ceftriaxone 1 gm IV q 24 hrs


Phlegmasia Cerulean Dolens*

know this

Literally inflammatory (edematous), blue, and painful, ie. painful, sky blue and inflamed!

Due to primary venous insufficiency with secondary arterial
insufficiency (not so in AF where emboli cause primary arterial occlusion and pallor occurs).

Most common cause is cancer, though may be obesity, old age, immobilization, or other procoagulantconditions (Factor V Leiden, etc)

so much venous insufficiency the leg swells up and blocks the artery, can tell primary problem is venous bc it is edematous and purple not white

goes with cancers


Phlegmasia alba dolens

is white one so it is an artery problem


Phlegmasia Cerulean Dolens*

1. Fluid
2. Anticoagulation
3. Evaluate for cancer


A 64 y/o male with lung cancer presents with dizziness, blurred vision and headache. Physical exam shows flushed faciesand dilated neck veins. This patient has developed

vena cava obstruction


Non small cell lung cancer is the most common cause of

vena cava syndrome* followed by small cell and then lymphoma . Pancoastssyndrome is more often d


Causes of SVC obstruction


Chronic fibrotic mediastinitis(reaction to

DVT from arm veins

Aortic arch aneurysm

Constrictive pericarditis

mroe swelling in face in morning bc gravity helps to drain


What causes lymphedema and what are its characteristics

partial agenesis of lymphatics

pitting edema without ulcers, varicose veins or stasis pigmentation

milroys disease

stewart treves syndrome


milroys disease 1892

–(described in a missionary from India)

–congenital lymphedema with break in the VEGFR 3 gene (know this (the gene controls lymphogenesis)


stewart treves syndrome

wont ask this

looks like lymphadema

actually a hemangiosarcoma rather than a lymphangiosarcoma due to local immunodeficiency (possibly radiation contributes)



doesnt involve feet is how you differentiate from lymphedema

adiposa deloroso, pain in fatty tissue