Vascular Disease

Question 1

Berry aneurysms

Answer 1

aka saccular aneurysms
occur at arterial bifurcations
20% if you have one, the are more
usually asymptomatic until it ruptures -> SAH
risks- smoking, HTN, dyslipidemia
angiogram and CT for SAH

Question 2

AAA

Answer 2

aortic aneurysms
usually asympomatic until rupture
expansion - mild to sever mid-abdominal pain that radiates to the lower back
abdominal aorta >3 cm, 90% infrarenal
may extended to common iliacs
found on PE or incidentally by ultrasound or CT
test of choice: ultrasound
monitor pts btwn 4-5 cm, tx with beta blockers
surgery - >5.5 cm, rapidly expanding, symptomatic pt
pt may need cardiac intervention before elective AAA repair
non-surgical pts - endoluminal stent
to accurate monitor growth of AA as it nears threshold : CT

Question 3

AAA rupture

Answer 3

sudden, severe, abdominal pain with radiation to back, huge drop in BP, emergent
anterior rupture fatal in minutes
posterior rupture may tamponade in retroperitoneum - allows time potentially for surgical repair

Question 4

AAA mortality

Answer 4

with repair - 1-5%
untreated 6-7 cm - 12% annually
greater than 7 cm - 25% annually
pts w/ AAA have 3X less risk with elective surgery than complications of rupture

Question 5

Thoracic aortic aneurysm

Answer 5

widened mediastinum on CXR
symptoms - dyspnea, stridor, cough , dysphagia, hoarse voice, superior vena cava syndrome
Dx: CT or MRI
Surgery : >5 cm, small but enlarging, compressing adjacent structures, traumatic in origin, >4.5 cm in Marfan’s pts
rupture: sudden onset CP w/ radiation to back

Question 6

Aortic Dissection

Answer 6

tear in intimal layer of aorta
sudden onset sever chest pain with radiation in interscapular region, abdomen, neck, HTN
may mimic MI or PE
risk - HTN, bicuspic aortic valve, coarctation or aorta, 3rd trimester pregnancy, Marfan’s syndrome and other connective tissue disorders
CXR - widened mediastinum - suggests dx
test of choice - CT (other options - MRI, TEE, MRA)
DeBakely and Stanford classifications
Tx - lower BP immediately w/ BBs and nitroprusside
ascending dissections require surgery
descending dissections tx medically at first, surgical if complicated or persistent symptoms

Question 7

DeBakey Classification

Answer 7

Aortic Dissections
type I - dissection starts in ascending aorta and extends at least to aortic arch and often beyond it distally
type II - dissecting starts in and is confined to ascending aorta only
type III - dissection in descending aorta, can extend distally

Question 8

Stanford Classification

Answer 8

aortic dissections
A - dissection of ascending aorta with or without aorta arch and descending aorta
B - Dissection involves descending aorta only

Question 9

Peripheral arterial Disease

Answer 9

aka peripheral vascular disease (PAD/PVD)
etiology - atherosclerosis
risks - smoking, hyperlipidemia, DM, HTN, CAD, CVA
often presents as claudication - calf, thigh, gluteal area pain while walking that lessens with rest, can progress
acute can be do to trauma or emboli
chronic can also present as non-specific leg symtpoms: aching, cramping, numbness, fatigue

Question 10

Evaluation of peripheral vascular system

Answer 10

arteries - 16X greater pressure, palpable due to left ventricular pressure
veins - pulsations are waves only visible no palpable
PE - part of head, neck, thorax, abdomen & extremity exam
inspect, palpate and auscultate arteries - temporal, external carotid, radial, ulnar, arch of aorta, abdominal aorta, common iliac, femoral, popliteal, dorsalis pedis, posterial tibial
- inspect for skin changes - hair loss, ulcerations, mottled
- fundoscopic exam
PAD - femoral bruits, diminished peripheral pulses, loss of hair, delayed capillary refill, dependent rub or elevation pallor

Question 11

Pulse presure

Answer 11

usually 30-40 mmHg
= SBP - DBP
widened - greater than 40 mm Hg : HTN, Aortic regurg, hyperthryoidism, patent ductus arteriousus, coarctation of the aorta, AV fistula
narrowed - < 30 mmHgL tachycardia, severe aortic stenosis, constrictive pericarditis, pericardial tamponade, ascites, others

Question 12

PAD - Dx

Answer 12

ABI
test of choice - arterial doppler ultrasound
angiography - gold standard

Question 13

PAD - Tx

Answer 13

anticoagulate with heparin
consider thrombolytic, angioplasty, embolectomy
conservative care for most pts - ASA, pentoxifylline or cilostazol, walk to develop collaterals, stop smoking
- can do surgical bypass grafts (ex: Fempop) and angioplasty w/ or w/o stenting

Question 14

Dry gangrene

Answer 14

starts as small, round, black lesion

as it extends it affected skin blackens, wrinkles, dries

Question 15

Wet gangrene

Answer 15

dry gangrene gets secondary infection - often mixed aerobic and anaerobic

• dead area and surrounding tissues swell
• fluids ooze onto surface

Question 16

Buerger’s Disease

Answer 16

aka thromboangiitis obliterans
inflammatory disease of the arteries
cigarette smokers, 20-40 year old males
symtpoms - cold limbs, tingling, burning numbness
signs - diminished arterial pulsations in affected limb, pallor on elevation, cyanosis on dependency, tender vein segments, trophic changes of digits and nails
tx - stop smoking or prognosis often includes amputation

Question 17

Raynaud’s

Answer 17

idiopathic, paroxysmal, b/l cyanosis of the digits due to arterial contraction or spasm
Disease - idiopathic
phenomen - precipitating condition (SLE, MM, autoimmune)
young females
usually digits of both hands, 50% of time feet too, digits eventually symetrically affected, moves proximally over time, 1-4 fingers involved
symptoms - provoked by exposure to cold/ emotion, numbness and tingling, pain, warmth relieves symptoms
PE - normal pulses, blanching during spasm phase for 15-60 min with sweat then cyanosis w/ pain then redness w/ warmth
tx - CCBs

Question 18

DVT

Answer 18

pain and/or edema of extremity
often asymptomatic
starts in calf veins and may propagate more dangerous to popliteal and or femoral veins
Dx - Homan’s sign unreliable
- D-dimer, normal - R/O DVT, high: 300-500, not specific
- test of choice - doppler compression ultrasound
- gold standard - venogram ( can also do impedance plethysmography)
tx: heparin - unfractionated IV w/ PT/PTT or LWMH SC (enoxaparin)
move to warfarin once pt therapeutic on heparin and follow INR
continue for 3-6 months uncomplicated, long term if complicated, cancer and DVT - LWMH regardless of risk
anticoagulation contraindications - green filter placement

Question 19

Virchow’s Triad

Answer 19

stasis, endothelial injury, hypercoagulable state

Question 20

Hypercoaguable states

Answer 20

post-op, pregnancy, estrogen, cancer, hospitalized w/ cardiac failure or CVA, protein C or S deficiency, anti-thrombin II deficiency, Factor V Leiden (most common), paroxysmal nocturnal hemoglobinuria

Question 21

PE

Answer 21

pulmonary embolism
clot from deep femoral system breaks off and embolizes to lung
very low risk for calf CVTs
CVTs above calf or propagating up from calf have incr. risk

Question 22

DVT prevention

Answer 22

early ambulation in hospital and post-op, SCDs, compresion stockings, LWMH or low-dose heparin subq, warafrin

Question 23

Edema

Answer 23

elevation of venous pressure causing less interstitial absorption and therefore more fluid accumulation
- caused by gravity, venous obstruction - thrombi, HF
PE - skin loses superficial landmarks, pitting at +10 lbs
-lymphedema- accumulation of interstitial fluid & lymph drainage
generalized - CHR, liver cirrhosis, nephrotic syndrome, malnutrition, CKD or ESRD
localized - thermal: burn or frostbite, trauma, allergic, inflammation, obstruction of lymph or veins
PE - visible veins: external jugular, cephalic, basilic, median basilica, greater saphenous, smaller veins on dorsum of ft and hands, others w/ incr. pressure or collateral stregthening

Question 24

Extremity drainage requirements

Answer 24

venous lumen patency
voluntary muscle contraction
competent valves in veins
deficiency - venous stasis

Question 25

venous stasis

Answer 25

edema, stasis pigmentation, ulceration - bacteria invade poorly nourished tissues
ex: varicose veins
chronic
- incompetent valves: varicosities, staisis dermatitis - edema, brownish color, ulcerations especially near malleoli
acute- superficial thrombophlebitis, DVT
- compression of lumen of vein from bedrest, immobilization, mass effect - lesion
-plugging of lumin - fibrosis, thrombi, neoplasms

Question 26

tx of veno-oclussive disease

Answer 26

compression therapy- external compression lessens pooling
sclerotherapy - veins injected w/ sclerosant - salt of chemical, hardens vein to prevent additional pooling
vein stripping- surgical, painful
ablation theraphy - electrical or laser injury to inside of vein

Question 27

Superficial thrombophlebitis

Answer 27

acute or chronic
no association w/ PE
causes - trauma, suppurative disease, ischemia, anemia, polycythemia, leukemia, idiopathic
PE: acute - pain, tender veins, local swelling, redness, warmth, palpable subq cord, edema, dependent cyanosis
chronic: same but less prominent