Vascular Disease

Question 1

Aortic Aneurysm: Definition, Pathophys, Etiology & comorbidities

Answer 1

• Definition: abnormal vessel dilation (1.5-2x normal size → 3cm). Progressive expansion → rupture. 95% affect abdominal aorta
• Pathophys:
  
  • degeneration of aortic wall & connective tissue inflammation
• Etiology:
  
  • commonly atherosclerosis
  • infx: TB, syphilis
  • Connective Tissue Disorder: Marfans, Ehlers-Danlos
• Comorbidities:
  
  • CAD, PVD, COPD, DM, renal failure

Question 2

Thoracic Aneurysm: Types, S/sxs, & Tx

Answer 2

• Types:
  
  • ascending thoracic aneurysm
  • aortic arch aneurysm
  • ascending thoracic aneurysm
• S/sxs:
  
  • Ascending:
    
    • compression (swelling in head, arms)
    • chest pain, back pain, neck pain
    • hoarseness
    • aortic regurg → heart failure
  • Arch & Descending:
    
    • wheezing, cough, SOB
    • hemoptysis
    • Hoarseness
    • dysphagia
    • chest pain, back pain
• Tx:
  
  • BP goal <140/90 (prefer 120/80)
  • with beta-blockers (decreases force of contraction into aorta) and ARBs (especially for Marfans)
  • Statins for atherosclerosis
  • smoking cessation
  • Surgery: indicated if ≥5.5cm, or growth > 0.5cm in 6-12 months

Question 3

Size & Types of Aneurysms

Answer 3

• Small aneurysm: 4cm
• Medium aneurysm: 5cm
• Larger aneurysm: > 5.5cm
• True aneurysm: involve all layers of the wall

Question 4

S/sxs of a Symptomatic Ruptured Aneurysm

Answer 4

abdominal pain & tenderness

pulsatile abdominal mass

hypotension

Question 5

Abdominal Aortic Aneurysm: risks, screening and s/sxs

Answer 5

• Risks: smoking, age >50, males,caucasians,atherosclerosis, family hx of AAA, other arterial aneurysms,connective tissue disorder, COPD, prior hx of aortic surgery
• Screening:
  
  • one time screening recommended for men >65 who have smoked or have first degree relative with ruptured/repaired AAA
• S/sxs:
  
  • Symptomatic unruptured:
    
    • back, abdominal, or flank pain
    • abdominal bruit
  • Symptomatic ruptured
    
    • abdominal pain & tenderness
    • pulsatile abdominal mass
    • hypotension

Question 6

Abdominal Aortic Aneurysm: Dx & Tx

Answer 6

• Dx:
  
  • Bedside abdominal U/S
    
    • used for diagnosis & to follow size
    • indicated if abdominal complaint or >3cm on exam
  • CT:
    
    • used to plan endovascular surgery
• Tx:
  
  • <5.5cm & asymptomatic: U/S f/u q 6-12 months
  • >5.5cm, symptomatic or rapid expansion (>0.5cm in 6-12 months): immediate surgical repair → open repair (if ruptured) or endovascular stent graft (if intact)
  • *endovascular is preferred*

Mortality:

• elective repairs 4-6%
• urgent repairs: 19%
• ruptures: 50%

Question 7

What increases rupture risk in aneurysms?

Answer 7

• large initial aneurysm diameter (>5.5cm)
• current smoking
• elevated BP
• greater aortic expansion rate (>0.5 cm/year)
• female gender
• symptoms

Question 8

Aortic Dissection: Definition, Etiology, & risks

Answer 8

• Definition:
  
  • a tear in the innermost vessel wall (tunica intima & part of media) → true and false lumen form→ compromised branch vessel flow → ischemia
    
    • starts in the thoracic aorta and may involve abdominal aorta
  • Ascending = most common (high mortality)
• Etiology:
  
  • non-traumatic dissections often occur in underlying aneurysm
  • trauma
• Risks:
  
  • HTN (most important), age > 50 yo, connective tissue disease (Marfan, Loeys-Dietz, Ehlers-Danlos), Pregnancy

Question 9

Aortic Dissection: S/sxs & PE

Answer 9

• S/sxs:
  
  • Acute onset of severe “tearing” chest pain (ascending), abdomen, or infrascapular (descending)
  • HTN (⅔ of patients)
  • anxious (“impending doom”)
  • neurological changes (transient or permanent)
  • distal ischemia (limbs, gut, kidney)
  • hypotension & shock if ruptured
• PE:
  
  • Unequal blood pressure in both arms
  • decreased peripheral pulses
  • hypertensive or hypotensive
  • hoarse voice
  • aortic regurg

Question 10

Aortic Dissection: Dx, Stanford Classifications & Tx

Answer 10

• Dx:
  
  • Spiral CT/CT Angiography: gold standard imaging
  • CXR: widened mediastinum, pleural capping or effusion
• Stanford Classification:
  
  • Type A: includes ascending aorta +/- aortic arch, descending aorta
  • Type B: descending aorta
• Tx:
  
  • Morality is 15-20% initially, then 1% per hour for the first 48 hours. Medical EMERGENCY!!
  • Initial Management:
    
    • reduce SBP (100 mmHg), LV dP/dT (force of blood leaving the ventricle), and pain
    • ***Beta-Blockers (1st line tx) to decrease contractility
      
      • then add vasodilators like Nipridine
  • Type A Management:
    
    • ascending aorta
    • Emergent surgery (mortality >48%)
  • Type B Management:
    
    • descending aorta
    • Medical therapy (if no rupture or ischemia)
      
      • surgery or endovascular therapy (if complicated –persistent pain, dissection, Marfans)

Question 11

Arterial Embolism/Thrombosis: Etiology, S/sxs, Dx, & Tx

Answer 11

• Etiology:
  
  • atrial fibrillation & mitral stenosis = common causes of thrombus formation
  • Lower extremities >>>> upper extremities
• S/sxs: 6 Ps** **of Arterial Occlusion:
  
  • 1.Pain
  • 2.Paralysis
  • 3. Pallor
  • 4.Paresthesia
  • 5.Polar (or Poikilothermia)
  • 6.Pulseless
• Dx:
  
  • Angiography = gold standard
  • ECG = look for MI or AFib
  • ECHO = looking for clot, MI, valve vegetation
• Tx:
  
  • anticoagulant with IV heparin
    
    • (bolus followed by constant infusion)
  • if not limb threatening then call the vascular surgeon for angioplasty, graft, or endarterectomy
  • Post-Op: watch out for compartment syndrome, hyperkalemia, renal failure from myoglobinuria, MIA

Question 12

Compartment Syndrome: Pathophys, S/sxs, PE, Dx, & Tx

Answer 12

• commonly seen after reperfusion of ischemic limb (typically calf) following a crush injury or tibial fracture
• Pathophys:
  
  • calf reperfusion → increased compartment pressures → compression of nerves, veins, & eventually arterial inflow
• S/sxs:
  
  • 6 Ps of Compartment syndrome:
    
    • 1.Pain out of proportion
    • 2.Passive stretch pain (i.e. when you bend the foot)
    • 3.Paresthesias
    • 4.Poikilothermia
    • 5.Paralysis
    • 6.Pulselessness
• PE:
  
  • Tense compartment (firm)
  • *frequent neurovascular checks are important *
• Dx:
  
  • compartment pressure > 30 mmHg = abnormal
  • Labs:
    
    • elevated creatinine kinase & myoglobin
• Tx:
  
  • Emergency fasciotomy with delayed closure often with skin grafts
  • *missing this may result in permanent nerve damage, such as foot drop or limb loss. May also result in death.

Question 13

Arteriovenous Malformation: Gen info, Risk factors, Epidemiology, S/sxs, & Dx

Answer 13

• General info:
  
  • Most dangerous of the congenital vascular malformations with a potential to cause intracranial hemorrhage and epilepsy in many cases
  • → usually present between 10-40 years of age
• Risk Factors:
  
  • Male
  • family hx
• Epidemiology:
  
  • Brain AVMs underlies 1-2% of all strokes, 3% of strokes in young adults, and 9% of subarachnoid hemorrhages
• S/sxs:
  
  • intracranial hemorrhage
  • seizure
  • headache
• Diagnosis: Angiography = GOLD standard

Question 14

Leriche Syndrome

Answer 14

Aortoiliac disease

decreased femoral pulses, impotence, buttock, & thigh claudication

Question 15

Peripheral Artery Disease: Definition, Sites, Risks, & Epidemiology

Answer 15

• Definition:
  
  • Atherosclerotic disease of the arteries of the lower extremities → progressive reduction of blood flow to the lower extremities. Most common form of peripheral vascular disease.
• Sites:
  
  • superficial femoral & popliteal (80-90%)
  • tibial & peroneal (40-50%)
  • *Atherisclerotic plaques frequently form occur at bifurctaions (Aortic, iliac, femoral) *
• Risks:
  
  • Elderly
• Epidemiology:
  
  • > 60 yo, 5% men, 2.5% women have symptoms of PAD. > 55yo 10% of pop has asymptomatic PAD

Question 16

Peripheral Artery Disease: S/sxs & PE

Answer 16

• S/sxs:
  
  • Claudication: crampy, tightening sensation in the calves when walking but resolves when stopped; >2 blocks is mild,1 block is moderate, <1 block is severe; development of collateral vessels may improve symptoms in 70% of patients
  • Rest pain: SBP <50 mmHg in legs, affects toes & dorsum of foot, may improve if place is food dependent (down)
• Presentation:
  
  • 1.asymptomatic
  • 2.atypical leg pain
  • 3.intermittent claudication
  • 4.Ischemic rest pain
• PE:
  
  • decreased or absent pulses
  • pallor with raised extremity
    
    • & dependent rubor (red when you put the extremity down)
  • Hair loss on leg/foot, atrophic skin & thickened nail beds
  • Arterial ulcers: outside of ankle, feet, heels or toes (punched out appearance)
  • leg pain, no swelling, cool
  • Necrosis & gangrene
  • Bruits: abdominal aorta, femoral, & popliteal arteries
  • Cool skin
  • Delayed cap refill

Question 17

Peripheral Artery Disease: Dx & Tx

Answer 17

• Dx:
  
  • Ankle-Brachial Index:
    
    • Normal >1.0
      
      • (>0.8 = no claudication)
    • Mild: 0.7-.99
    • Moderate: 0.5-0.69
      
      • (0.5-0.8 = claudication)
    • Severe: <0.5 (rest pain)
    • Limb threat: <0.2

*calcified vessels prevent BP cuff from compressing → false reading

• Tx: Stop-Start Walking Regimen
  
  • regular daily walks (30-45min) 3x/week for at least 6 months.
  • -walk as fast & far as possible using near maximal pain as a signal to stop & then resume walking when the pain goes away
    
    • → pt can walk 120-180% farther with training because they are recruiting more collaterals
  • Management:
    
    • Smoking cessation (greatest benefit)
    • Lipid & HTN therapy
    • Aspirin +/- clopidogrel
    • Pentoxifylline (decreases RBC viscosity)
  • surgical management → if affecting lifestyle, rest ischemia, or limb threat
  • revascularization: aortofemoral bypass graft
  • All pts with claudication should undergo medical eval for CV risk b/c it is a marker for atherosclerosis

Question 18

Phlebitis/Thrombophlebitis: Definition, Etiology, risk factors

Answer 18

• Definition:
  
  • inflammation of the wall of the vein which can then lead to clot formation
• Etiology:
  
  • spontaneous, or after trauma or IV/PICC lines
• Risk Factors:
  
  • local trauma, recent IV, drug use or hypercoagulable state

Question 19

Phlebitis/Thrombophlebitis: PE, Dx, & Tx

Answer 19

• PE:: palpable cord (incompressibility of a superficial vein)
  
  • erythema, tenderness/pain, swelling
• Dx:
  
  • Venous Duplex U/S = gold standard
    
    • → noncompressible vein with clot and vein wall thickening
• Tx:
  
  • Phlebitis: elevation, warm or cool compresses, NSAIDs
  • Thrombophlebitis: (Phlebitis + Thrombosis) with anticoagulation (heparinx 1 month)

Question 20

Varicose Veins: Definition, Risks, & Epidemiology

Answer 20

• Definition:
  
  • dilation of superficial veins due to failure of the venous valves in the saphenous veins → retrograde flow, venous stasis, & pooling of blood
• Risks: family hx, females, elderly, standing for long periods, obesity, increased estrogen
• Epidemiology: develop in 10-20% of adults, esp pregnant women

Question 21

Varicose Veins: S/sxs, PE, & Tx

Answer 21

• S/sxs:
  
  • *may be asymptomatic*
  • dull ache or pressure sensation in area of varicosities that is worse with standing or sitting with the leg dependent edema, relieved with elevation (unlike arterial disease)
• PE:
  
  • dilated visible veins
    
    • telangiectasia
    • swelling
    • discoloration
    • may rupture with local bleeding → ulceration
• Tx:
  
  • Conservative: compression stockings, leg elevation, pain control
  • Sclerotherapy, laser therapy, vein stripping
  • frequent short walks, do not sit/stand more than 45-60 minutes

Question 22

Venous Insufficiency: Definition, S/sxs, PE, & Tx

Answer 22

• Definition:
  
  • changes due to venous HTN of the lower extremities as a result of venous valvular incompetency → veins become rigid & thick-walled. May occur after DVT, superficial thrombophlebitis or trauma
• PE:
  
  • venous ulcers: form below the knee and on the inner area of the ankle
  • inflammation
  • swelling
  • stasis dermatitis: itchy eczematous rash, excoriations, weeping erosions & brownish or dark purple hyperpigmentation
  • dependent pitting leg edema
• Tx:
  
  • leg elevation (30 min 3-4x/day)
  • compression stockings (knee or thigh high) & exercise to increase deep venous flow
  • -diuretics to reduce edema
  • -abx secondary to edema
• Ulcer Management:
  
  • apply dressing to promote re-epithelialzation
  • compression bandaging system
  • wound debridement

Question 23

Venous Thrombosis: Definition, Risk Factors, PE, Dx, & Tx

Answer 23

• Definition: clot formation in the veins
• Risk Factors: Virchow’s Triad, stasis, vascular injury, hypercoagulable state (OCP, cancer, surgery, factor V leiden)
• S/sxs:
  
  • generalized pain
• PE:
  
  • edema
  • Positive Homan’s sign (extend the leg and push the foot towards the head with pain in the calf)
• Dx:
  
  • Venous Duplex U/S = first line imaging
  • D-Dimer: negative D-dimer will rule out DVT in low risk patients
  • Venography = GOLD Standard
• Tx:
  
  • overall: Heparin to warfarin bridge
  • immediate anticoag => LMW heparin, or the oral factor Xa inhibitors