vascular disease

Question 1

arterial occlusion

Answer 1

can occur centrally (Aortoilliac)

but generally start peripherally (Femoral, Popliteal, Infrapopliteal)

Typical Etiology:
Atherosclerosis
Often the first sign of disease elsewhere (CAD)

Other Etiologies:

Diabetes: Distal lower extremities, esp. feet, diabetic foot wounds

Thromboembolic: Limbs

Question 2

typical arterial occlusion at

Answer 2

White, Male, Age 50-60, Smokers

Question 3

The 5 “P”s of Arterial Occlusion

Answer 3

Pain
Pallor
Pulselessness (weak/absent distal to the occlusion)
Paresthesias
Paralysis (need to intervene!)

Question 4

Pain

Answer 4

Claudication: Severe Cramping associated with exertion
Can be variable, “intermittent”
Inability of blood flow to tissue demands

Question 5

other manifestations of arterial occlusion

Answer 5

Muscle atrophy

Erectile Dysfunction

Loss of hair of distal extremities

Skin Changes:
Hyperemia, Cyanotic, Dusky Appearing, Cool to Touch

Question 6

arterial occlusion dx:

Ankle-Brachial Index (ABI)

Answer 6

The ratio of systolic blood pressure detected by doppler examination at the ankle compared to the brachial artery

Normal: ABI 1.0-1.2

Reduced Blood Flow: ABI less than 0.9

Question 7

art occ dx: critical limb ischemia

Answer 7

Elevated Myglobin (renal failure with rhabdomyalysis)

Metabolic Acidosis

-will be in pain at this point

Question 8

art occ imaging

Answer 8

Angiography with CT or MR

Mainly for Intervention to Identify affected vessels

-look for runoff:
right pic: left leg lacks runoff

Question 9

art occ conservative tx

Answer 9

Exercise, weight loss, smoking cessation

Cilostazol (PDE-inhibitors (maintain patency, inc. blood flood)

Antiplatelet agents (ASA, Clopidogrel)

*prevent extension of clot

Question 10

art occ tx: Endovascular Techniques

Answer 10

Angioplasty and Stenting

Question 11

art occ tx: sx techniques

Answer 11

Endarterctomy

Bypass Grafting

Question 12

Critical Limb Ischemia tx

Answer 12

Heparin
Catheter Directed tPA
Thrombectomy

Complications:
Compartment syndrome
Fasciotomy

Question 13

aneurysm

types??

Answer 13

Pathologic dilation of a BV

saccular (bulge)
fusiform (long and slender)
giant
dissection: high pressure blood flow opens false lumen in intima–>clot, hematoma formation

Question 14

Diseases Associated with Aneurysms

Answer 14

*Aortic Aneurysms
Berry Aneurysms
Peripheral Aneurysms

Question 15

congenital etiologies of aneurysms

Answer 15

Marfans Syndrome: defective elastin gene

Ehler-Danlos Syndrome: defective collagen gene

Question 16

acquired etiologies of aneurysms

Answer 16

Age
HTN
Smoking, pollution?
Inflammation
Atherosclerosis
Syphilis (mycotic aneurysm)
Trauma
sx procedures i.e. bypass grafts

Question 17

Abdominal Aortic Aneurysm (AAA)

Answer 17

Present when Aorta diameter >3cm

Increase risk of rupture >5cm

Found in 2% of men over age 55

90% originate below renal arteries (but before bifurcation)

4:1 Male predominance

Question 18

AAA s/s

Answer 18

80% of 5cm infrarenal AAA are palpable
Usually found incidentally on CT or U/S
Pain
Rupture

Question 19

AAA pain

Answer 19

Mild-severe abdominal discomfort
Often radiate to the lower back
Intermittent or constant
Exacerbated with abdominal pressure

Question 20

AAA rupture

Answer 20

Sudden onset severe pain w/ blood in the retroperitoneum
Palpable mass can be present
Hypotension
medical emergency!

Question 21

AAA imaging: 1st choice

Answer 21

Abdominal ultrasound is test of choice:
Screening test
USPTF: recommended in Men 65-74yrs with smoking history (not Women)

Question 22

AAA imaging 2nd choice

Answer 22

CT abdomen:
Useful to assess for size and location
Planning for intervention
Monitor Progression

Question 23

conservative AAA tx

Answer 23

Smoking Cessation
Manage HTN
Serial Imaging 
every 2 yrs if less than 4cm
every 6 mos around 5cm

Question 24

elective sx repair for AAA when ??

Answer 24

> 5.5cm diameter OR

>0.5cm increase in diameter in 6 months

Question 25

AAA: Absolute Indication for Surgery Consult when ??

Answer 25

Signs suggestive of Rupture or impending rupture: Acute onset severe abdominal pain with radiation to the back Hypotension Cullen Sign: periumbilical ecchymosis Grey Turner’s Sign: flank ecchymosis (both signs imply retroperitoneal hemorrhage)

Question 26

Thoracic Aortic Aneurysm s/s

Answer 26

less than 10% of all aortic aneurysms ``` Signs and Symptoms Severe persistent substernal chest pain Radiation to the back/neck Usually Hypertensive Dyspnea, stridor, dysphagia, hoarseness UE Edema ```

Question 27

Thoracic Aortic Aneurysm imaging

Answer 27

``` Chest Xray: Widened mediastinum *CT Chest*: Modality of Choice Echocardiography: may see dilated aortic root, bicuspic aortic valve ```

Question 28

Thoracic Aortic Aneurysm tx: only monitoring when ??

Answer 28

Stable Descending Aortic Aneurysm

Question 29

TAA tx: endovascular repair for ??

Answer 29

Descending Aortic Aneurysm

Question 30

surgical intervention for TAA

Answer 30

Any Ascending Aortic Aneurysm -Especially when carotid and left subclavian arteries involved Descending Aortic Aneurysm >6cm in diameter

Question 31

Conditions associated with increased risk of aortic dissection:

Answer 31

Pregnancy Bicuspid aortic valve Coarctation of the Aorta

Question 32

aortic dissection s/s

Answer 32

``` Severe persistent substernal chest pain Radiation to the back/neck Usually Hypertensive Dyspnea, stridor, dysphagia, hoarseness UE Edema Diastolic Murmur Intestinal ischemia Diminished /unequal peripheral pulses Acute Heart Failure Pericardial Tamponade ```

Question 33

aortic dissection imaging

Answer 33

CT Chest and abdomen: modality of choice see false lumen

Question 34

aortic dissection med tx

Answer 34

Aggressive HTN management Beta blockers, Nitroprusside Morphine for pain

Question 35

aortic dissection sx

Answer 35

Urgent all Type A Type B affecting left subclavian artery

Question 36

Venous Insufficiency May be associated with ??

Answer 36

``` Obesity Previous leg trauma Previous DVT Varicose veins Neoplastic obstruction AV fistula (congenital or acquired) ```

Question 37

Venous Insufficiency basic pathology

Answer 37

Valve leaflets do not close Increased Hydrostatic Pressure Causes characteristic Skin changes

Question 38

venous insufficiency s/s

Answer 38

``` Progressive Pitting Edema Secondary skin changes: Edema (pitting) Fibrosis Hyperpigmentation-Hemosiderin deposition Thickening of the subcutaneous tissue Pruritis Ulceration Impaired wound healing decreased sensation lack of hair ``` ``` dusky appearance, dec. sensation, cooler NOT cellulitis (would be warm) ```

Question 39

venous insufficiency tx

Answer 39

Fitted Graduated Compression Stockings Avoidance of long periods of time sitting/standing Intermittent elevation