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Flashcards in vascular disease Deck (39):
1

arterial occlusion

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

2

typical arterial occlusion at

White, Male, Age 50-60, Smokers

3

The 5 “P”s of Arterial Occlusion

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

4

Pain

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

5

other manifestations of arterial occlusion

Muscle atrophy

Erectile Dysfunction

Loss of hair of distal extremities

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

6

arterial occlusion dx:
Ankle-Brachial Index (ABI)

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

7

art occ dx: critical limb ischemia

Elevated Myglobin (renal failure with rhabdomyalysis)

Metabolic Acidosis

-will be in pain at this point

8

art occ imaging

Angiography with CT or MR

Mainly for Intervention to Identify affected vessels

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

9

art occ conservative tx

Exercise, weight loss, smoking cessation

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

Antiplatelet agents (ASA, Clopidogrel)

*prevent extension of clot

10

art occ tx: Endovascular Techniques

Angioplasty and Stenting

11

art occ tx: sx techniques

Endarterctomy

Bypass Grafting

12

Critical Limb Ischemia tx

Heparin
Catheter Directed tPA
Thrombectomy

Complications:
Compartment syndrome
Fasciotomy

13

aneurysm

types??

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

14

Diseases Associated with Aneurysms

*Aortic Aneurysms
Berry Aneurysms
Peripheral Aneurysms

15

congenital etiologies of aneurysms

Marfans Syndrome: defective elastin gene

Ehler-Danlos Syndrome: defective collagen gene

16

acquired etiologies of aneurysms

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

17

Abdominal Aortic Aneurysm (AAA)

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

18

AAA s/s

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

19

AAA pain

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

20

AAA rupture

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

21

AAA imaging: 1st choice

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

22

AAA imaging 2nd choice

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

23

conservative AAA tx

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

24

elective sx repair for AAA when ??

>5.5cm diameter OR
>0.5cm increase in diameter in 6 months

25

AAA: Absolute Indication for Surgery Consult when ??

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)

26

Thoracic Aortic Aneurysm

s/s

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

27

Thoracic Aortic Aneurysm imaging

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

28

Thoracic Aortic Aneurysm tx: only monitoring when ??

Stable Descending Aortic Aneurysm

29

TAA tx: endovascular repair for ??

Descending Aortic Aneurysm

30

surgical intervention for TAA

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

31

Conditions associated with increased risk of aortic dissection:

Pregnancy
Bicuspid aortic valve
Coarctation of the Aorta

32

aortic dissection s/s

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

33

aortic dissection imaging

CT Chest and abdomen: modality of choice


see false lumen

34

aortic dissection med tx

Aggressive HTN management
Beta blockers, Nitroprusside
Morphine for pain

35

aortic dissection sx

Urgent
all Type A
Type B affecting left subclavian artery

36

Venous Insufficiency May be associated with ??

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

37

Venous Insufficiency basic pathology

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

38

venous insufficiency s/s

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)

39

venous insufficiency tx

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