Flashcards in Vascular Deck (44):
2 types of aneurysms
Saccular (outpouching, mushroom)
Fusiform (entire diameter grows)
Difference bt aneurysm and dissection
aneurysm = all layers of arterial wall (intima, media, adventitia)
dissection = defect in intima, allows blood to go bt layers
Branches of abd aorta
95% of abd aneurysms are distal to the takeoff of the renal arteries.
PhysEx for abd ao aneurysm
pulsatile abd mass
lower extremity pallor, cool temp, unequal/diminished pulses
Diagnostic eval for abd aneurysms
US- size and if there's a clot in the arterial lumen
CT or MRI- anatomic detail and localization
Aortogram- can check for involvement of other vessels, help plan surgery
Rx for abd ao aneurysm
If asx: depends on size-
<4cm medical- beta blockers
4-5cm- can do early op or can do close followup.
5+cm surgical repair.
surgery- new use of stent grafts via femoral
If ruptured/leaking- fluids and immed op
Surgical repair of AAA
midline incision or oblique over 11th IC space.
Midline: push bowel to right, incision of posterior peritoneum to the L of the Ao exposes entire Ao.
Oblique- only for retroperitoneal approach. Entire peritoneal contents pushed to right, exposing Ao.
Get prox and distal control, give heparin before clamping, place graft w permanent sutures.
If transabd approach, close peritoneum over graft.
branches off of thoracic aorta
brachiocephalic, L common carotid, L subclavian, bronchial arteries, esophageal, intercostal arteries
Cause of thoracic Ao aneurysms
Cystic medial necrosis or atherosclerosis
less common- trauma, dissection, infection
HPE for thoracic Ao aneurysm
Most are asx
if ruptured- chest pain/prs
if expanded- can compress tracha --> cough, if erodes into trachea --> hemoptysis
if close to Ao valve, can cause dilation of the annulus--> Ao insuff and chest pain, dyspnea, syncope
on physEx- hypotension, tachycard
if involves annulus, ao regurg and CHF
Dx Eval for thoracic Ao aneurysm
CXR- wide mediastinum
EKG- myocardial ischemia
If asx- do CT or echo
Aortography for planning op
Rx for thoracic Ao aneurysm
If asx, operate if 5+cm
Sxtic- immed op
Why do Ao dissections occur (path)?
HTN, trauma, Marfan syndrome, Ao coarctation
HPE Ao dissection
Immediate onset severe pain, tearing, in chest, back, abd.
Also nausea, lightheadedness
May be hypotensive, may have diminished periph pulses
Dx Eval of Ao dissection
CXR- wide mediastinum
CT- may show dissection or clot in arterial lumen
Dx via TEE, MRI, or aortogram
Classifications of Ao dissection
DeBakey Type I: both ascending and descending Ao
Type II: just ascending
Type III: just descending
Rx for Ao dissection
Depends on type. DeBakey Type II (ascending)- surgery! bc can go retrograde to Ao root. Give anti-HTN before surgery to halt progression
DeBakey Type III (descending)- medical only. give anti-HTN: Na+Nitroprusside and B Block.
From where does the common carotid arise?
On right side: from brachiocephalic (which comes off of Ao)
On left: directly from Ao.
What arteries does the common carotid branch into?
Bifurcates into Internal and External branches.
Internal carotid gives of opthalmic artery, then continues to circle of willis in brain.
Why does carotid artery disease occur (pathogenesis)?
But you get the stroke bc of plaque rupture, ulceration, hemorrhage, thrombosis, low flow states.
Pt Hx in carotid artery dz
Prev neurologic events:
TIA (24 hr resolution); fixed neuro deficit
What is amarosis fugax
transient mono-ocular blindness
shade being pulled down.
d/t occlusion of a branch of the opthalmic artery (which is a branch of the internal carotid
PhysEx in carotid artery dz
May have fixed neuro deficit
Hollenhorst plaques on retinal exam = evidence of previous emboli
Carotid bruit - evidence of turbulent carotid flow
Dx Eval of carotid artery dz
Carotid duplex scanning
Angiography more accurate for assessing degree of stenosis
Rx for carotid artery dz
Depends on Hx, degree of stenosis, and plaque characteristics.
Anti-plt therapy w aspirin prevents neurologic events
If acute event and CT confirms it's non-hemorrhagic: give heparin
Carotid endarterectomy only in serious pts.
Stenting being researched.
What patients should get a carotid endarterctomy?
>70% stenosis + sx
bilateral dz + sx
>50% stenosis and recurring TIA despite aspirin
Carotid endarterectomy procedure
IV abx (1st gen ceph) before incision
Incision over anterior border of SCM
ligate facial vein --> expose carotid
carotid is just medial to JV
don't injure hypoglossal nerve or spinal accessory nerve.
give heparin, open artery, dissect out plaque.
close with patch.
What is the celiac axis?
arterial supply to liver, spleen, pancreas, stomach
thrombosis of which vein can cause visceral ischemia?
Superior mesenteric vein
Acute ischemia of mesentery occurs how? (path)
mesenteric vein thrombosis
Acute mesenteric ischemia- HPE
May have hx of prev embolic events, Afib, CHF.
Abd pain is sudden and severe, w diarrh/vom
Pain out of proportion to exam
Abd may be distended
Rectal exam - guaiac+ stool
Chronic mesenteric ischemia- HPE
Hx of crampy abd pain after eating--> decrsd oral intake and weight loss.
can have naus/vom/diarrh/constipation
Can be mistaken for malignancy d/t weight loss
May have abd bruits, guaiac+ stool, PVD or CAD
Dx Eval of acute mesenteric ischemia
elevated WBC, metabolic acidosis, elevated hematocrit (d/t fluid sequestering in infarcted bowel)
Abd XR normal early on, but later shows thumbprinting of bowel wall.
Rx of acute mesenteric ischemia
Laparotomy, exam and resect any infarcted bowel.
Sometimes angiography can be dxtic/therapeutic.
Mortality extremely high even with intervention.
Rx for acute mesenteric vein thrombosis
Laparotomy if there is susp of necrotic bowel
Peripheral vascular dz occurs in what arteries?
Common and superficial femoral
Even tho there are 3 vessels that supply the ankle/foot, you only need 1 to be adequate for life.
Pathogenesis of acute vs chronic PVD
acute- caused by embolus, usu from Ao or heart (Afib)
chronic- from progressive atherosclerotic dz--> narrowing of lumen and decreased blood flow
HPE of acute PVD
sudden/severe lower extremity pain and paresthesias.
pain, parasthesia, pulselessness, pallor, poikilothermia (coolness)
HPE of chronic PVD
claudication- pain on activity, relieved on rest.
butt claudication = aortoilliac dz; calf claudication = femoral atherosclerosis.
may have ulcers too.
can have loss of hair, pallor on elevation, rubor on dependent positioning, wasting, thick nails, thin skin
Dx Eval of PVD
Angiography for acute PVD
doppler for chronic (normal = triphasic. as progresses, becomes bi, mono, then absent.
Arteriography is gold standard for defining level/extent of dz and surgery planning
Ankle brachial index in PVD
Claudication ABI = 0.5
Rest pain ABI = 0.3-0.5
Gangrene ABI = <0.3
Rx for acute ischemic embolus in PVD
heparin, thrombolysis, embolectomy
Rx for chronic ischemia in PVD
smoking cessation and graded exercise