Vascular disorders (arterial) Flashcards by Maya Birchler

What PAD does this indicate:
Pain into thigh/buttocks/groin
ED
Weakness in legs when walking
Extreme limb fatigue
Pain relief with rest and starts again when walking
Leriche’s syndrome = claudication in buttock/thigh, impotence + decreased femoral pulse

aorta-iliac

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What PAD does this indicate:
Intermittent claudication confined to thigh + upper ⅓ of calf
Dependent rubor of foot (improvement w/ lifting)
Atrophic changes in lower leg - loss of hair, thinning of skin/subcutaneous tissues, disuse atrophy of muscles

femoral + popliteal

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What PAD does this indicate:
1st = Ischemic ulcer or foot gangrene (NO claudication)
Ischemic rest pain confined to dorsum of forefoot, lower calf (relieved with dependency/increased blood flow by gravity)
Does not occur w/ standing, sitting, or dangling
Severe + burning
Awaken from sleep (MC at NIGHT)
atrophic skin changes, non healing wounds

Tibial + pedal

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What are risk factors for PAD?

> 70 years old or ~50 w/ risk factors (DM or tobacco use)

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What PAD is most common in white men 50-60 who smoke cigarettes?

aorta-iliac

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What PAD is most common in black and latino patients, from atherosclerosis ~1 decade after development?

femoral + popliteal

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What PAD is most common in diabetic patients, extensive calcification, claudication may not be present?

tibial and pedal

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What causes PAD?

atherosclerotic lesions in extremities

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What is diagnostic for aorta-iliac + femoral-popliteal?

ABI<.9

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What would this PE indicate
PE: Femoral pulses + distal pulses absent or weak with bruits of aorta, iliac, femoral
Dx: ABI <.9, exaggerated by exercise, CTA + MRA (only when symptoms require intervention)

aorta-iliac PAD

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What would this PE indicate
PE: Common femoral pulsation normal, popliteal + pedal pulses reduced
Dx: ABI <.9 is diagnostic, <.4 = limb-threatening, duplex ultrasound, CTA and MRA (only if revascularization is planned, but must be monitored)

femoral-popliteal PAD

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What would this PE indicate
PE: femoral + popliteal pulses may/may not be present, absent pedal pulses, dependent rubor w/ pallor on elevation, skin of foot - cool, atrophic, hairless
Dx: often ABI <.4, digital subtraction angiography is gold standard, MRA/CTA less helpful
NOT plantar surface burning + not relieved w/ leg dependency

tibial-pedal PAD

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What is gold standard in tibial-pedal PAD diagnosis?

digital subtraction angiography

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When should you admit an aorta-iliac PAD?

Evidence of chronic limb-threatening ischemia (resting pain + tissue loss)
Acute limb ischemia (needing IV anticoagulation + surgery)

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When should you admit a femoral-popliteal PAD?

REFER IF - progressive symptoms, short-distance claudication, rest pain, ulceration
ADMIT IF: chronic limb threatening ischemia or foot infection

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When should you admit a tibial-pedal PAD?

ADMIT IF: any patient w/ DM and foot ulcer + infection (emergent I&D) with broad spectrum abx

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Lateral

arterial

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Medial

venous insufficiency

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What is the cornerstone of aorta-iliac PAD treatment?

cardiovascular risk reduction + exercise program
- smoking cessation
- weight loss

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How do you treat aorta-iliac PAD?

antiplatelet therapy (aspirin or clopidogrel)
low dose rivaroxaban w/ aspirin
high dose statin
cilostazol (walking distance improvement)
endovascular therapy (best for single stenosis)

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What is a surgical intervention for aorta-iliac PAD?

Prosthetic aorta-femoral bypass graft (highly effective), graft from axillary artery, contralateral femoral artery graft

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What’s first line for a femoral-popliteal PAD?

medical + exercise therapy, risk factor reduction
- antiplatelet therapy (aspirin or clopidogrel)
- low dose rivaroxaban w/ aspirin
- high dose statin
- cilostazol (walking distance improvement)

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What’s general treatment for all PAD?

antiplatelet therapy (aspirin or clopidogrel)
low dose rivaroxaban w/ aspirin
high dose statin
cilostazol (walking distance improvement)

and lifestyle changes

CARS. Cilostazol anti platelet rivaroxavan statin

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When should you surgically intervene for a femoral-popliteal PAD?

Progressive claudication, incapacitating, interferes significantly w/ essential daily activities or if pain at rest or ulcers threaten foot
–>
Bypass surgery (femoral-popliteal using autologous saphenous vein)

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What are alternative treatments for femoral-popliteal PAD??

Endovascular techniques – angioplasty + stenting in patients undergoing aggressive risk factor modification with smaller lesions Thomboendarectomy to remove plaque

What's first line treatment for tibial-pedal PAD?

Prevent ulcers, revascularization to avoid major amputation if ulcer appears + not healing Bypass + endovascular techniques (saphenous vein) Amputation

What is Leriche's syndrome and what is it associated with it?

claudication in buttock/thigh, impotence + decreased femoral pulse aorta-iliac PAD

What are the 6 Ps of acute arterial occlusion of a limb?

Pain Pulseless Pallor Paresthesia Paralysis Poikilothermia

What are symptoms of acute arterial occlusion of a limb?

Sudden onset of extremity pain, loss or reduction in pulses, neurologic dysfunction, pallor, coolness, mottling

What could cause acute arterial occlusion of a limb?

History of claudication A fib (MC)

What causes acute arterial occlusion of a limb?

Embolism or thrombosis of diseases atherosclerotic segment >50% from heart → LE, 20% → cerebrum Pre-existing CAD or PAD + claudication

What could this indicate: PE: low capillary refill, decreased/absent pulses, cool temperature

acute arterial occlusion of a limb

What diagnostic methods are useful for acute arterial occlusion of a limb?

Duplex US is 1st imaging choice Doppler + lab = little to no flow in vessels with myoglobinuria + metabolic acidosis Consider CT angiography

How do you treat first line acute arterial occlusion of a limb?

Immediate revascularization + heparin

What are other ways to treat acute arterial occlusion of a limb?

Endovascular techniques - pharmacomechanical thrombectomy catheters, catheter directed thrombolysis, immediate revascularization Surgical intervention

What do these symptoms indicate: Asymptomatic If symptomatic - Pain (mild-severe mid abdominal pain radiating to lower back), constant/intermittent, exacerbated by gentle pressure Rupture = severe pain + HOTN Abdominal bruit

AAA

What's the most common cause of AAA?

infrarenal arteries

If AAA is ruptured, what are the key symptoms?

acute abdominal, flank, back pain + abdominal distention + hemodynamic instability

What are risk factors for an AAA?

Males, >55 years, smoking, HTN, atherosclerosis

When is an AAA considered present?

>3 cm

90% of AAAs are ____ the renal arteries

below

Refer for AAAs diameter is ____

>/ 4.5cm

When do you admit for an AAA?

tender aneurysm to palpation, signs of aortic rupture, evidence of infection

What are ways to diagnose AAA?

PE: pulsatile mass on routine PE → order US (unstable) or CT w/ contrast (stable)

What is the test of choice for AAA?

abdominal US

With acute AAA rupture, what may a patient have?

Hct normal, but may have CAD, carotid disease, kidney disease, emphysema

What preemptive screening should you do for AAAs?

1 time screening via ultrasound of men 65-75 years old w/ exposure to 100+ cigarettes, q10 years if 2-2.9cm

How often should you have an US for a 3-3.9cm AAA?

q3 years

How often should you have an US for a 4-4.9cm AAA?

q12 months

How often should you have an US for a 5+cm AAA?

q6 months with contrast

When should you electively repair an AAA?

5.5cm or larger in men or 5 cm in women OR >.5cm in 6 months OR symptomatic

What are other ways to treat AAA?

endovascular repair, underlying cause and surgically (based on size, compression of retroperitoneal structures, pain upon palpitation) --> open surgical aneurysm repair, endovascular aortic repair

What do these symptoms indicate: Most are asymptomatic, OR substernal back/neck pain, pressure on trachea, esophagus, SVC (dyspnea, stridor, brassy cough, dysphagia, edema in neck/arms, distended neck veins, hoarseness)

TAA

Are AAA ruptures lethal?

Are TAA ruptures lethal

yes

What can cause TAA?

atherosclerosis or rarely syphilis, connective tissue disorders

What is the modality of choice for a TAA?

CT scan w/ contrast

When should you refer a TAA patient?

ascending >4.5cm, descending >5cm

What does this CXR indicate: calcified outline of dilated aorta, widened mediastinum

TAA

How do you treat an ascending aorta TAA?

~5.5cm -- open surgery required, repari

How do you treat a descending aorta TAA?

>/5.5cm, endovascular grafting

What are symptoms of PAAs?

6 Ps: Pain Pulseless Pallor Paresthesia Paralysis Poikilothermia and pulsatile mass when in groin

Where is a peripheral artery anuerysm normally?

popliteal artery

Is an anuerysm normal in the femoral artery?

no, not very common, normally a pseudoaneurysm, following punctures for arteriography/cardiac

What are diagnostic tips of peripheral artery aneurysms?

Duplex color US, MRA or CTA, arteriography, abdominal US if found to evaluate for AAA If prominent or easily felt pulse in popliteal = suggestive + get US Often bilateral (and many have AAA) Unequal = PAA

How do you treat PAAs?

Immediate surgery when acute embolization or thrombosis has caused acute ischemia (open surgical bypass) Indicated when - Ass w/ peripheral embolization - >2cm - Mural thrombus present

How do you treat a pseudoaneurysm femoral artery?

Pseudoaneurysm femoral artery – US compression or thrombin injection

How do you treat a primary femoral aneurysm?

Primary femoral aneurysm - Open surgery w/ prosthetic interposition grafting

What does this characterize: Severe, persistent chest pain sudden onset that radiates down the back or into anterior chest, possibly into neck Uncontrolled HTN, syncope, hemiplegia, paralysis of lower extremities, mesenteric ischemia or kidney injury, peripheral pulses diminished/unequal, diastolic murmur Abdominal pain, neuro findings

aortic dissection

What can predispose someone to aortic dissection?

Pregnancy, bicuspid aortic valve, bovine arch, coarctation, HTN

What are the two types of aortic dissection?

A and B - A revolves around the Arch, and B resolves around the lower part. No arch = can't be A

What causes aortic dissection?

Spontaneous intimal tear w/ blood dissecting into media of aorta from repetitive torque, HTN

What could this indicate: Asymmetric BP New aortic regurg murmur EKG: LVH CXR: abnormal aortic contour or widened superior mediastinum

aortic dissection

What could indicate rupture in an aortic dissection?

HOTN

HTN is most common with Type _ of aortic dissection

What imaging is gold standard for an aortic dissection?

multiplanar CT w/ contrast

If a patient is unstable, what diagnostic should you do?

TEE

Admit for aortic dissection if

acute needing urgent surgical repair (ALL Type A and Type B with malperfusion, rupture, symptoms, uncontrolled BP)

Yearly ____ to monitor aortic dissection development

Aortic dissection is an ____

emergency

How do you treat an acute aortic dissection?

beta blockers (cardioprotective) + BP control (sodium nitroprusside or nicardipine) --> 100-120/60-70

What are additional treatments for aortic dissection?

IV CCBs - nicardipine Additional - nitroprusside for HTN Morphine sulfate for pain Long term BB for HTN

How do you treat a Type A dissection?

urgent, transfer to appropriate facility

How do you treat a Type B w/ malperfusion?

URGENT if aortic branch compromise

How do you treat a Type B w/o malperfusion?

BP control

Vascular disorders (arterial) Flashcards

(85 cards)