Vascular Disease Flashcards
(80 cards)
1
Q
Describe the findings
A
DVT
- US images:
- thin walled vein + not collapsible with compression –> DVT
2
Q
What are other significant doppler/US findings of LE DVT?
A
- anechoic thrombus
- increased venous diameter
- loss of phasic flow with breathing
- augmentation with calf squeeze
- absence of color flow
3
Q
Describe US findings:
- Baker’s cyst
A
well-circumscribed mass + echolucent center
4
Q
Describe US findings:
- arterial stenosis
A
- atheroma and stenosis are visualized
- confirmed by spectral Doppler –>
- significant increase in velocities (flow accelearation)
5
Q
Describe US findings:
- Polyarteritis nodosa
A
- small aneurysms
- beads of a rosary (“rosary sign”)
- most commonly involved organ = kidney
6
Q
How does large artery atherosclerosis lead to cerebral ischemia?
A
- thromboembolism from the atherosclerotic plaque
-
direct occlusion of the penetrating arteries by the plaque
- especially in the case of intracranial atherosclerosis
- hemodynamic perturbations <– plaque related stenosis
7
Q
What is the Class I indication for carotid endarterectomy?
A
TIA / CVA « 6 months secondary to –>
moderate to severe ( ► 50% stenosis ) extracranial carotid stenosis
8
Q
What is an alternative to carotid endarterectomy?
- symptomatic ( CVA / TIA « 6 months)
- moderate-severe ( ► 50% stenosis)
A
Endovascular stenting (Class IIa)
- should be reserved for highly selected cases with:
- extracranial vertebral artery stenosis
- limited evidence
9
Q
Describe the difference in treatment and outcomes for intracranial atherosclerotic disease:
- medical therapy
- endovascular stenting
A
- stenting has worse outcomes compared to best medical therapy
- should only be performed when best medical therapy has failed
10
Q
What are the recommended first line antiplatelet therapies for secondary prevention of ischemic stroke?
A
- ASA
- Clopidogrel
- ASA/extended-release dipyridamole
****DAPT is not recommended over monotherapy with any of these agents
11
Q
What is the mortality rate associated with?
- Type A aortic dissection
- aortic root / SoV involvement
A
- Without operation:
- First 24 hours –> 1-2% / hour
- First 48 hours –> 50%
12
Q
What is the mortality associated rate?
- Type B aortic dissection
A
- In-hospital –> 8%
- 5 years –> 60-80%
13
Q
Describe the initial treatment strategy for acute aortic dissection?
A
- Decrease wall stress by controlling:
- HR
- LV contractility
- change in pressure / change in time [dP / dT]
- Beta blockers
14
Q
What BB’s are utilized in the acute aortic dissection?
A
- Metoprolol
- Labetalol
- Esmolol
- Propanolol
15
Q
What are the indications for TEVAR in type B aortic dissection?
A
- Malperfusion syndrome (end-organ ischemia)
- Early expansion
- Rupture
- Refractory pain
16
Q
What are the indications for surgery?
- Acute
- Type A dissection
A
All patients
17
Q
What are the indications for surgery?
- Acute
- Type B dissection
A
- Rupture
- Rapid Aneurysm Expansion
- Extension
- Malperfusion syndrome
- Marfan Syndrome?
18
Q
What are the indications for surgery?
- Chronic
- Type A dissection
A
- ► 5.5 cm
- ► 1 cm / year increase in dimension
- Severe AR
- Symptoms suggestive of:
- expansion or
- compression
19
Q
What are the indications for surgery?
- Chronic
- Type B dissection
A
- ► 6 cm
- ► 1 cm / year increase in dimension
- Symtpoms suggestive of:
- expansion or
- compression
20
Q
What are three genetic risk factors / mutations for aortic aneurysm and dissection?
A
- FBN1
- fibrillin-1 gene
- Marfan’s syndrome
- TGFB1-2
- transforming growth factor beta 1 and 2 gene
- Loeys-Dietz syndrome
- COL3A1
- Collagen type 3 alpha 1 gene
- Vascular Ehlers-Danlos
21
Q
What patients are at increased risk of PAD?
A
- Age ► 65 years
- Age 50-65 years + risk factors (DM, tobacco abuse, dyslipidemia, HTN) or FH PAD
- Age < 50 years + DM and 1 additional risk factor for atherosclerosis
- Known ASCVD in another bed
- coronary, carotid, subclavian, renal, mesenteric artery stenosis, AAA
22
Q
Describe the diagnostic testing algorithm for suspected PAD?
A
23
Q
What is the next step?
- history or PE suggestive of PAD
- ABI > 1.4 (noncompressible vessels)
A
Toe-brachial index (TBI)
- « 0.70 = abnormal
24
Q
What is the mortality associated with a diagnosis of PAD?
A
- 5- year risk of CV death –> 25-30%
- Nonfatal MAACE –> 20%
25
What are the benefits of exercise ABI?
* Diagnosing PAD in patients with:
* claudication and
* normal ABI at rest
* Discriminating claudication from pseudoclaudication
* Assessing functional capacity
26
What constitutes further anatomic assessment in PAD?
When should this be performed?
* Duplex US, CTA, MRA or invasive angiography
* Performed with revasculrization is planned
27
What patient should be screened for PAD?
1. 52-year old woman with pale feet when lying in bed, reddish color when standing
2. 84-year-old woma with a draining ulcer over the medial malleolus
3. 73-year-old man with pain and tingling in both legs while walking, reduced with bending forward
**1. - 52-year-old woman with pale feet when lying in bed, reddish color when standing**
* elevation pallor and dependent rubor --\> PAD
* 84 year old with draining ulcer --\> venous insufficiency ulcers
* arterial ulcers tend to be dry
* 73-year old with tingling in both legs bending over
* neurogenic claudication --\> spinal stenosis
28
Describe the findings
**Raynaud phenomenon**
* exaggerated vascular response to cold temperature or emotional stress
* Secondary RP - triggers:
* Autoimmune diseases
* systemic sclerosis
* SLE
* mixed connective tissue disease
* Sjogren syndrome
* dermatomyositis/polymyositis
* Drugs / Toxins
* BB
* Clonidine
* Sympathomimetics
* Stimulants **(Methamphetamines)**
* Cyclosporine
* Cisplatin
* Bleomycin
29
What are the indications for carotid duplex prior to CABG?
* \> 65 years of age
* LM stenosis
* PAD
* Tobacco abuse (history of)
* TIA/CVA (history of)
* Carotid Bruit
30
Describe the findings
**Cholesterol emboli syndrome (CES)**
* nonspecific symptoms
* livedo reticularis
* renal failure
* mesenteric ischemia
* Treatment:
* supportive
* **increase statin therapy**
31
What is the most common cause of atheroembolism?
**iatrogenic - \> 70%**
* secondary to catheter-based angiography or vascular surgery
32
What is diagnostic of obstructive PAD on exercise ABI?
**decrement of \> 20%**
* functional testing is important to evaluate for PAD in patients with exertional symptoms **(Class I)**
33
What is the BP goal in acute ischemic stroke?
* no thrombolytics
**\< 220 / 110 mmHg**
* should be tailored based on comorbid conditions
34
What is the BP goal in acute ischemic stroke?
* thrombolytics given
* prior to administration of thrombolytics = **\< 180 / 110 mmHg**
* 24 hours post-thrombolysis = **\< 180 / 105 mmHg**
35
What is the window for tpa in acute ischemic stroke?
**\< 4.5 hours**
36
Define acute limb ischemia (ALI)
* vascular emergency
* requires rapid assessment of, to determine limb viability and salvageability:
* arterial perfusion
* venous perfusion
* sensory function
* motor function
* revascularization is performed emergently
37
Describe diagnostic testing, findings and treatment of ALI:
* Category I: Viable limb
* Dopplers:
* Audible arterial
* Audible venous
* Category I: Viable limb
* Normal motor function
* No sensory loss
* Intact capillary refill
* Urgent **(Class I)**
* Anticoagulation
* Revascularization
38
When should limbs be revascularized in ALI?
* Viable limbs --\> **within 6-24 hours**
* Threatened limbs --\> **« 6 hours**
39
Describe the diagnostic/treatment algorithm for ALI
40
Describe diagnostic testing, findings and treatment of ALI:
* Category IIa: Marginally threatened
* Dopplers:
* **Inaudibale arterial**
* Audible venous
* Motor/Sensory function assessment:
* **Intact motor function**
* Sensory loss limited to toes if present
* slow-to-intact capillary refill
* Emergent **(Class I)** - salvageable if treated promptly
* Anticoagulation
* Revascularization
41
What is the diagnosis?
* acute ischemic cerebral syndrome (R hemiparesis)
* preceded by:
* neck pain
* ptosis
* miosis
**carotid dissection**
* Horners syndrome --\>
* Ptosis and Miosis
* symptoms are the result of distension of nerve fibers on the outer surface of the internal CA
* **25% of cases**
42
Describe diagnostic testing, findings and treatment of ALI:
* Category III: Irreversible
* Dopplers:
* **Inaudibale arterial**
* **Inaudible venous**
* Motor/Sensory function assessment:
* **Complete loss of motor function**
* **Complete sensory loss**
* **Absent capillary refill**
* Emergent (Class I)
* **Primary amputation**
43
Describe the findings post-PCI?
What is the best way to confirm the diagnosis?
* **Cholesterol Embolization Syndrome (CES)**
* Biopsy
* only for clinical situations in which diagnosis is unclear
44
What is the appropriate screening recommendation for AAA based on size at diagnosis?
* \> 2.5 cm - \< 3 cm --\> **10 years**
* 3 cm - 3.9 cm --\> **every 3 years**
* 4 cm - 4.9 cm --\> **every 12 months**
* 5 cm - 5.4 cm --\> **every 6 months**
45
What are the indications for elective repair of an asymtpomatic AAA?
* \> 2.5 cm - « 5.5 cm;
* **► 5.5 cm --\> repair**
* **women (consider) ► 5.0 cm**
* Rapid expansion; and
* AAA associated with peripheral arterial aneurysms or PAD
46
What are treatments to improve symptoms of claudication in PAD?
* **supervised exercise program**
* Cilostazol
* contraindicated in heart failure
* Endovascular therapy
* effective and reasonable in patients with inadequate response to exercise and medical therapy
47
Describe diagnostic testing, findings and treatment of ALI:
* Category IIb: Immediately threatened
* Dopplers:
* **Inaudibale arterial**
* Audible venous
* Motor/Sensory function assessment:
* **Mild or moderate muscle weakness**
* **Sensory loss more than toes and with rest pain**
* **slow-to-absent capillary refill**
* Emergent (Class I) - salvageable if treated **emergently**
* Anticoagulation
* Revascularization
48
Define critical limb ischemia (CLI)
* chronic ( \> 2 week) ischemic rest pain
* nonhealing wound/ulcers or gangrene in one or both legs
* attributable to objectively proven arterial occlusive disease
49
What are the requirements to proceed with PFO catheter closure?
* embolic-appearing ischemic stroke
* without other etiology despite adequate testing
* 18-60 years of age
50
What is the recommendation for anticoagulation in cryptogenic stroke with presence of PFO?
**Not recommended (Class III harm)**
* unless other indication present (A-fib, h/o DVT, mechanical heart valve)
51
Describe the findings
* Incorrect electrode placement ( +1 )
* abrupt R-wave increase in lead V2 followed by much smaller R wave in V3
* V2 is actually V6
* **Atrial tachycardia ( +4 )**
* P-waves of sinus origin should be positive in lead II
* PVC's ( +1 )
* Inferior MI, age indeterminant or probably old ( +1 )
52
Describe the findings
* **Atrial flutter ( +4 )**
* LAD ( +1 )
* LVH ( +1 )
* RVH ( +1 )
* RBBB, incomplete ( +1 )
53
Describe the findings
* NSR ( +1 )
* LAE ( +1 )
* **AV block, second degree, Mobitz I (Wenckebach) ( +4 )**
54
Describe the findings
* NSR ( +1 )
* **AV block, second degree, Mobitz I (Wenckebach) ( +4 )**
* LAD ( +1 )
* IVCD, nospecific type ( +1 )
* QRS slightly widened (approximately 115 ms) but criteria for LBBB are not met
55
Describe the findings
* NSR ( +1 )
* **PAC's ( +2 )**
* single dropped beat toward the end of the tracing
* T-wave preceding this dropped beat has a slightly different morphology
* PAC burried within the T wave --\> dropped beat
56
Define May-Thurner syndrome
* rarely diagnosed condition in which patients develop ileofemoral DVT and recurrent DVTs
* anatomical defect:
* the R common iliac artery overlies and compresses
* the left common iliac vein against the lumbar spine
* present in \> 20% of the population
57
What are common risk factors / presenting symptoms in May-Thurner syndrome?
* scoliosis
* pregnancy (recent)
* OCP
* LLE DVT's (rather than RLE DVT's)
* LLE swelling (in the absece of DVT's)
* female sex
58
What is the best method of diagnosis in suspected May-Thurner syndrome?
**CT or MR venography of the pelvis**
* gold standard --\> contrast venography
* has been replaced due to its invasive nature
59
What is the recommendation for screening in family members of a patient with?
* bicuspid aortic valve
* aortic aneurysm
**CTA or MRA of aorta in first-degree relatives**
* especially when a family history of thoracic aortic aneurysm and/or aortopathy
60
Define critical limb ischemia (CLI)
severe PAD associated with:
* rest pain
* nonhealin ulcers
* gangrene
61
What is the recommendation for DAPT in severe PAD (CLI)?
not recommended
* has not been demonstrated to provide incremental benefit
62
What is the diagnosis and next best step?
* 78 year old woman
* HA's, visual disturbances, jaw fatigability with chewing, shoulder stifness
* Giant cell (temporal) arteritis
* large-vessel vasculitis
* **Temporal biopsy**
63
What is the diagnosis and next best step?
* 38 year old woman
* tobacco abuse and ulcers on fingertips
**Buerger's disease (thromboangitis obliterans)**
* most important therapy = smoking cessation
64
What is the diagnosis and next best step?
* 28 year old Asian woman
* mild fevers and arm fatigue when brushing her hair
**Subclavian stenosis / possible Takayasu arteritis**
65
What are the recommendations for surgery for TAA disease based on size and rate of growth of aneurysm?
66
What are the recommendations for medical thearpy in TAA?
* BB (atenolol)
* ARB/ACE (losartan)
67
Describe Takayasu Arteritis
* \< 50 years of age
* 80-90% are women
* inflammation (**thickening)** of:
* aortic arch
* and stenosis of its branches
68
What laboratory test may help in the diagnosis of cholesterol embolization syndrome?
**Urine eosinophils**
69
When calculating ABI, what brachial BP should be used?
**higher of the two**
* subclavian stenoses may cause decreases BP in one arm
70
What is the diagnosis and next best step?
* 75 year old woman with severe substernal chest pain
* PMH: HTN, dyslipidemia, prior carotid endarterectomy
* Meds: ASA, Rosuvastatin, Carvedilol, HCTZ
* VS: HR 98, BP 169/102
* Labs: Troponin negative
* CT: crescentic, high attenuation area measuring approximately 3 mm in diameter in the posterior ascending aorta, that does not enhance with contrast. No involvement of the great vessels or arch. No intimal flap or compression of the lumen.
* **Type A intramural hematoma (IMH)**
* **Emergent surgical consultation**
* ****high risk of rupture
* mortality with medical therapy alone ~40%
71
What medications are contraindicated in acute aortic syndromes?
**Vasodilating drugs - Hydralazine**
* should not be given prior to adequate beta-blockers
* **Class III recommendation**
72
What are the "5 Ps" of limb ischemia?
* pain
* pallor
* paralysis
* pulselessness
* paresthesia
73
What are the types of acute aortic syndromes?
* Aortic dissection
* Intramural hematoma
* Penetrating aortic ulcer
* Rapid Aneurysm expansion
* Aortic Rupture
74
Why is vitamin K not the reversal agent of choice in intracranial hemorrhage?
* slow reversal
* earliest effect on INR in 2 hours
* peak effect 6-12 hours
75
What is the agent of choice for reversal?
* acute cerebral hemorrhage
* warfarin use
* INR 3
**4F-PCC 1500 units**
* contains purified vitamin K-dependent clotting factors
* do not require ABO compatibility and can be stored at room temperature
* dosing:
* INR and
* bodyweight
76
What is the reversal agent for Dabigitran?
**Idarucizumab**
77
Describe the findings
* NSR ( +1 )
* AV junctional rhythm / tachycardia ( +1 )
* AV block, third degree ( +4 )
* Inferior MI, age recent or probably acute ( +4 )
78
Describe the findings
* NSR ( +1 )
* LAE ( +1 )
* **AV block, second degree, Mobitz II ( +4 )**
* Nonspecific ST and/or T wave abnormalities ( +1 )
79
80
Define posterior reversible encephalopathy syndrome (PRES)
* acute encephalopathy that appers to be related to **disordered cerebral autoregulation** and **endothelial dysfunction**
* acute severe hypertesion (beyond upper limits of cerebral autoregulation) --\> **Vasogenic edema**
* ****MRI brain
* focal bilateral areas of cerebral edema
* posterior portion of the brain (particularly occipital lobes)
