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Vascular Ds Flashcards

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1
Q

Atherosclerotic Peripheral Vascular Disease: Blockage at Aorta & Iliac

Who has increased risk?

A

30% occurrence in 70 yo without risk factors
30% occurrence in 50 yo with risk factors

Risk factors:
-diabetic
- tobacco use****
- >70 yrs
- MC: white obese male smokers age 50-60 yo

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2
Q

Atherosclerotic Peripheral Vascular Disease: Blockage at Aorta & Iliac description ( what arteries location, progression, mortality)

A

-Systemic atherosclerotic process
-Lesions in the distal aorta and proximal common iliacs
-Progression may lead to complete occlusion of one of both iliac arteries
-Mortality from the cardiac disease is 25-40% at 5 years

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3
Q

Atherosclerotic Peripheral Vascular Disease: aorta and iliac S&S

A

⅔ asymptomatic or not classic symptoms
MC: Intermittent Claudication (local muscle pain with movement)
- Pain is secondary to insufficient blood flow when there is an increased demand from exercise
- Starts as CALF cramping → Thigh & Buttock pain → Erectile dysfunction → Pain during rest
- sx are relieved with rest and reproducible with the same exertion! (compare w stable angina)
- pts may dangle foot off bed so gravity helps
- Bruit may be heard over aorta, iliac, or femoral artery (check belly button bruits)

Leriche’s Syndrome:*
- Claudication
- Absent/Decreased Femoral Pulse
- Impotence

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4
Q

Leriche’s Syndrome: what are the signs and what is this associated with

A

Leriche’s Syndrome:*
- Claudication
- Absent/Decreased Femoral Pulse
- Impotence

Atherosclerotic Peripheral Vascular Disease: aorta and iliac

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5
Q

Atherosclerotic Peripheral Vascular Disease: aorta and iliac work up

A

Ankle Brachial Index:
- Compares blood pressure in upper limbs vs lower limbs to determine if there is abnormal decreased perfusion
- ABI = BPAnkle / BPArm
- If ABI < 0.9 = Peripheral Artery Disease
- If ABI < 0.4 = Critical Limb Ischemia
-Exaggerated by exercise
-ABI measured using the dorsalis pedis and posterior tibial arteries

CT angiography and MRI:
- identify anatomic location of the lesion
- CT Angiography: cautious with CKD: could damage nephron from contrast

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6
Q

atherosclerotic peripheral vascular disease: aorta and iliac tx medical and risk factor management

A
  • STOP SMOKING! (biggest risk)
  • Exercise Program: walking is the best*, optimal weight
    -Lipid and HTN management: High dose statin for plaque stabilization
    -Plavix daily, High dose statin daily
    -Phosphodiesterase inhibitors (Pletal/cilostazol): helps with cramping
    -Aspirin: reduces cardiovascular morbidity
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7
Q

atherosclerotic peripheral vascular disease: aorta and iliac tx surgical

A

Angioplasty and stenting: efficacy - closure/renarrowing in 30-50%!
-Bypass surgery (Axillo-femoral, fem-fem bypass) patency 90% at 5 years

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8
Q

atherosclerotic peripheral vascular disease: femoral and popliteal description

A

-Usually occurs 10 yrs after aortioiliac disease
-Frequently at the site where the superficial femoral artery passes through the abductor magnus tendon in the distal thigh (adductor hiatus)
-Less common in common femoral and popliteal but these lesions are debilitating

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9
Q

atherosclerotic peripheral vascular disease: femoral and popliteal sx + signs

A

-Calf cramping
-Rubor (red) of the foot with blanching on elevation (Buerger’s Test)
-Reduced popliteal and pedal pulses (Would NOT have reduced FEMORAL PULSE)

Atrophic changes in the lower leg and foot:
-Loss of hair, thinning of skin & tissue, atrophy of muscle.
-gangrene or ulcers (severe)
- should only have toe nails cut by podiatrist

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10
Q

atherosclerotic peripheral vascular disease: femoral and popliteal work up/dx

A

Reduced ABI: <0.9

Anatomical Location of Lesion determined by:
- Duplex Doppler ultrasound: do first!
- CT Angiography: CI with renal insufficiency since contrast is processed in kidneys
- MRI

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11
Q

atherosclerotic peripheral vascular disease: femoral and popliteal tx risk factors and medical

A

-Risk factor reduction
-Exercise Program

Medical therapy same as Aortioiliac:
- High dose Statin daily (Atorvastatin) for plaque stabilization
- Phosphodiesterase Inhibitors
- clopidegrel(plavix) daily
- Aspirin to reduce cardiovascular morbidity

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12
Q

atherosclerotic peripheral vascular disease: femoral and popliteal tx surgical

A

Femoral- Popliteal Bypass

Angioplasty and stenting (if less than 10 cm):
-1 yr patency 50% angioplasty, 80% stenting
-3 yr restenosis common : <50% pts have patency and have restenosis

Thromboendartectomy:
- for common femoral & profunda femoris -> Where bypass and stenting less successful

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13
Q

atherosclerotic peripheral vascular disease: tibial and pedal description

A

-Severe pain in the FOOT that is relieved by dependency (using gravity to help blood flow)
-Pain or numbness in the foot with walking (no blood supply)
-Primarily in diabetics: Due to chronic vessel damage from hyperglycemia
- high rates of amputation

TP = FOOT fetish

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14
Q

atherosclerotic peripheral vascular disease: tibial and pedal sx and signs

A

-May not have claudication symptoms -> usually just pain in the FEET
-Rest pain & Ulcerations: Critical limb ischemia! High rate of amputation

Sx:
-Pedal pulses absent
-Pallor on elevation
-Skin cool, atrophic and hairless
-pt typically awakened with dorsal foot pain -> Pain relieved with dangling foot off bed

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15
Q

artherosclerotic peripheral vascular disease: tibial and pedal work up and tx

A

ABI low (<0.4 = critical limb ischemia)

Digital subtraction angiography *

MRI and CT NOT as useful with small vessels

Tx:
-Good foot care
-If non-healing ulceration after 2-3 weeks: revascularization to avoid amputation
-Bypass to distal tibial: 70% patent at 3 years.
-Amputation if needed

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16
Q

acute aterial occlusion of limb -Signs and Symptoms

A

Six P’s:
- Pain
- Pulselessness
- Pallor
- Poikilothermia: Inability to regulate constant body temp
- Paresthesia: can’t feel it
- Paralysis: can’t move it (end stage)

Pain is often localized and less severe when the limb is in the dependant position
-As the ischemia prolongs, paresthesia replaces pain and the final stages of injury cause paralysis*

Livedo reticularis:
- lacy pattern on the skin -> Mottled vascular pattern*

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17
Q

What is acute arterial occulsion of a limb + source/cause of occlusion

A

-SUDDEN pain in an extremity with an absent extremity pulse*

Source of acute arterial occlusion:
-Cardiac emboli (think AFib)
-thrombosis - endocarditis
- hyper coagulable state: (hormone therapy, cancer, obese, sedentary)

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18
Q

acute arterial occlusion of a limb workup

A
  • Little to no flow on Doppler US
  • If suspicious of acute arterial occlusion, STRAIGHT TO THROMBOEMBOLECTOMY (emergency!!!)
    -Don’t delay with an MRI or CT, only with low suspicion
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19
Q

acute arterial occlusion of a limb tx

A

IMMEDIATE REVASCULARIZATION! - Should be within 3 hrs, by 6 hrs irreversible!

IV heparin: prevent clot from getting bigger

Tissue plasminogen activator: TPA - breaks down clot

Thromboembolectomy: clot removal
-10-25% risk of amputation, 25% hospital mortality rate

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20
Q

Occlusive Cerebrovascular Disease definition, causes

A

Definition:
- blood vessels that supply the brain become narrowed/blocked

Caused by:
- Atherosclerotic Disease in the CAROTIDS
- EMBOLI
- TIA (seconds to minutes): temporary blockage of blood flow to the brain -> reversible event if perfusion is restored, but now higher risk for future stroke..
- stroke (>24h): block of blood flow to brain; ischemic or hemorrhagic

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21
Q

1/4 ischemic strokes come from ____ source. 90% result from a problem in the ______ artery.

A

1/4 of ischemic strokes come from an ARTERIAL source
90% of these resulting from a problem in the PROXIMAL INTERNAL CAROTID ARTERY

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22
Q

Occlusive Cerebrovascular Disease presentation

A

Marked by:
- Sudden onset of weakness and numbness of extremities or face
- Aphasia: cannot understand speech
- Dysarthria: difficulty speaking for a few seconds *
- Unilateral blindness (Amaurosis Fugax)*
-Carotid artery bruit: loudest mid neck

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23
Q

occlusive cerebrovascular disease: workup

A

-Duplex Ultrasound for carotid stenosis
-MRA
-CTA

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24
Q

occlusive cerebrovascular disease: tx

A

CVA management

If >60% carotid stenosis: INTERVENTION
-Carotid Endartectomy
-Angioplasty and stenting*
-25% will have recurrent CVA if no intervention

If 30-50% stenosis:
- MONITOR and risk factor modification
-F/u with US monitoring

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25
1/4 ischemic stroke=___________ source
arterial source, 90% from proximal internal carotid artery
26
visceral artery insufficiency definition
Embolus or Thrombus to major mesenteric vessel (SMA, IMA) -Usually two of three vessels have occlusive disease if symptoms being there is collateral circulation (celiac, SMA, IMA, marginal) Acute is emboli or thrombus to major mesenteric vessel - Often pain out of proportion to initial clinical findings -> 10/10 pain with no PE findings -Low flow state from CHF or hypotension Chronic: - adequate at rest but ischemic when flow demands increase after eating -Severe post prandial abdominal pain -Weight loss with fear of eating
27
visceral artery insufficiency definition + acute vs chronic
Definition: - Emboli or Thrombus to major mesenteric vessel (SMA, IMA) - Since there is collateral circulation (SMA, IMA, Marginal), 2 vessels must be occluded to be symptomatic Acute: - Significant pain that is unproportional to clinical findings - Pt presents with 10/10 pain that is out of proportion but they look ok -> internal visceral pain concern Chronic: - Adequate at rest but ischemic when flow demands increase after eating - Severe post prandial abdominal pain - pt loses weight and appetite
28
When you have a post op aortic patient , they have a large bowel movement? Whats happening?
-Ischemic colitis -> IMA intestinal mucosa will slough -> Consider in post operative aortic patient! -if pt has LARGE BOWEL MOVEMENT post op -> concern for ischemic bowel because you block off blood flow - bowels are trying to clear out everything Ischemic Colitis: LLQP tenderness, cramping diarrhea bloody - no blood flow to IMA
29
visceral artery insufficiency: S&S acute vs chronic vs ischemic colitis
Acute: - severe, steady epigastric and periumbilical pain -No findings on PE (visceral not parietal peritoneum) -High WBC, lactic acidosis, hypotensive, abdominal distention Chronic: - evidence of other atherosclerosis -> Epigastric or periumbilical pain lasting 1-3 hrs after eating - Pt presents with cramping pain everytime they eat -> wt loss - Can lead to ischemic colitis Ischemic colitis: - left lower quadrant pain and tenderness - abdominal cramping - mild bloody diarrhea
30
visceral artery insufficiency: workup
Work Up: -CT with contrast -US may show proximal lesion. -Colonoscopy: show ischemic colitis changes
31
visceral artery insufficiency: tx
Treatment: -Acute: Surgical exploration -Chronic: angioplasty and stenting Ischemic colitis tx: - Supportive care until collateral circulation is established - If bowel becomes necrotic, must be RESECTED - fatal if no intervention
32
thromboangitis obliterans/buerger disease definition and presentation
Definition: -Inflammatory and thrombotic process of the DISTAL most arteries and occasionally the veins. -vasculitis due to smoking! Presentation: -male smoker less than 40 yrs!!!!* -Severe ischemia of the feet, fingers and hands. -Pain in distal extremity - tissue loss and amputation unless they stop smoking
33
thromboangitis obliterans/buerger disease work up and tx
Work up: -MRA or invasive angiography Treatment: -Stop smoking!
34
giant cell arteritis definition and presentation
Definition: -Systemic inflammatory condition of the MEDIUM and LARGE vessels -Large vessel problems occur in 15% of patients within 7 years -complication: blindness Pt presentation: - MC: older than 50 yrs old with polymyalgia reheumatica (autoimmune ds) -May have varicella / zoster relationship -pt complains of unilateral temporal headache, Scalp tenderness, jaw claudication, throat pain, diplopia and elevated inflammatory markers.
35
What artery does giant cell arteritis involve?
Frequently involves TEMPORAL artery and other branches of the CAROTID artery
36
giant cell arteritis: workup and tx
Work Up: -ESR and C-reactive protein elevated -Temporal artery biopsy -Temporal US: may show thickening Treatment: -High dose prednisone - low dose Aspirin
37
aortic aneurysm definition and ethiologies
Definition: -Weakness and subsequent dilation of the vessel wall - Asymptomatic until rupture Ethiologies: - atherosclerotic damage to the intima: MC* - genetic defect - syphilis - giant cell arteritis - vasculitis - trauma - Marfan syndrome, Ehlers- Danlos syndrome AGC GS VT - atherosclerotic damage - genetic - connective tissue ds - giant cell arteritis - syphyllis - vasculitis - truma
38
90% of AAA are below: ______ arterties. It usually involves the ______ and what arteries?
90%: below renal arteries Usually involve: - aortic bifurcation and common iliac arteries
39
Greater than ____cm is diagnostic AAA, risk of rupture occurs when greater than ___cm. How many cm is the mass palpable on PE?
Dx: 3cm If > 5 cm diameter: - High risk of rupture - mass is palpable on exam
40
Who are AAA most common in?
MALE smokers
41
aortic aneurysm S&S
Asymptomatic until rupture: -Most found as an incidental finding on US or CT -Pain During rupture: - severe pain - palpable abdominal mass (>5 cm) - hypotension -Lethal
42
aortic aneurysm: screening
Screen: - men 65-75 yo smokers -women: 1st degree relative with Hx of AAA Screening dx imaging: -Abdominal Ultrasound* -CT scan: use for diameter and anatomical location
43
How often do you surveil someone diagnostically w AAA diameter of greater than 3cm?
Annual ultrasound!!! -Every 6 months US if mass is approaching 5 cm CTA with contrast: - to define anatomy for repair once mass reaches 5 cm
44
AAA tx: indication, CI, and what is tx
Tx indication: - >5.5 cm or rapid expansion (0.5 cm in 6 months) - needs VASCULAR SURGERY INTERVENTION - CI to tx: if life expectancy < 2 years -MI complication 10% with surgical repair Open Surgical Repair: - Graft is sutured to the nondilated vessel above and below - replacing the aneurysmal segment of the aorta with a synthetic graft -> "like replacing weak part of a hose with synthethic tube" Endovascular Repair: - A stent graft line aorta and exclude AAA -less invasive option-> placing a stent graft within the aorta to exclude the aneurysm from blood flow, thereby reducing the risk of rupture
45
thoracic aortic aneurysm sx and signs
Most = asymptomatic sx: -Back and neck pain* -dyspnea - stridor, cough, - dysphagia - hoarseness (recurrent laryngeal) * - distended neck veins If aneurysm in ascending aorta = may involve aortic valve If rupture = FATAL
46
On XRAY what may be observable for a thoracic aortic aneurysm? what other imaging would you request for thoracic aortic aneurysm?
CXR may show widened mediastinum CT scan -If > 6 cm = Repair -Surgical vs endovascular repair -Surgical risk of paraplegia -> risk of vertebral artery loss (supply to spinal cord)
47
thoracic aortic aneurysm tx and tx indications
CT: -If > 6 cm = Repair Surgical or endovascular repair: -Surgical risk of paraplegia -> risk of vertebral artery loss -> supply to spinal cord lost -> spinal infarct " There is risk of paraplegia due to proximity of spinal arteries = spinal infarct"
48
thoracic aortic aneurysm risk factors
HTN 50-60 yo Collagen disorder Vasculitis Family Hx
49
peripheral artery aneurysms presentation
Usually silent until critically symptomatic. -Present as embolization or thrombosis Presentation: - asymptomatic/silent -70% popliteal with 60% bilateral involvement - 50% of pts also have a AAA -Pulsatile mass
50
peripheral artery aneurysms dx + tx
Diagnosis: - US to investigate - CTA/MRA to define - Also screen for AAA Tx: - surgical repair with bypass
51
aortic dissection definition and sx
Definition: -Spontaneous tear in inner layer of aorta (intima) and blood dissects into the media of the aorta - could lead to aortic rupture + reduced blood flow to organs Sx: -Acute SEARING/RIPPING retrosternal chest pain with radiation to the back, abdomen or neck* -HTN -> no blood flow to renal -> increase contractility -Syncope -hemiplegia: paralysis on one side of the body* - paralysis of lower extremities -Intestinal ischemia and renal insufficiency may develop -Pulses may be diminished or unequal in upper extremities
52
aortic dissection dx + tx
- MR Angiography: GOLD standard with 100% sensitivity and specificity - CT Chest/Abd for dx - CXR: widened mediastinum Treatment: - Surgery is A MUST
53
varicose veins definition and who do they occur in
Definition: -Superficial veins distended due to progressive venous reflux - incompetent valves -Distribution of great saphenous vein Who do they occur in? -20% of adults -women who have been pregnant - obese - family history - prolonged sitting or standing
54
varicose veins sx and tx
Sx: -Can be asymptomatic or ache proximal to varicose veins Conservative Tx: - Elastic stockings - leg elevation - exercise for relief Surgical tx: - Surgical stripping - thermal ablation - sclerotherapy
55
superficial venous thrombophlebitis definition + Where would superficial venous thrombophlebitis typically occur?
Definition: -Partial or complete occlusion of a vein and INFLAMMATORY changes where would they typically occurs: -Usually at the site of a recent IV line -> Staphylococcus aureus infection* -Spontaneous - site of varicose veins -Can be caused by systemic hypercoagulopathy in abdominal cancer!!*
56
superficial venous thrombophlebitis sx and tx
sx: -Induration, redness and tenderness along a superficial vein tx: -Spontaneous tx: heat and NSAIDs -Antibiotics for infectious causes
57
chronic venous insufficiency definition + common causes/associations
Definition: -Loss of wall tension in veins causing stasis of venous blood in the lower extremities - breakdown of leaked Hb from blood into the interstitial space -> hemosiderin depositis -> dark pigmentation -Prevention is key! Common causes/associations: - DVT - leg injury - varicose veins: valve dysfunction
58
chronic venous insufficiency sx + signs
-Progressive pitting edema starting at the ankle followed by skin and subcutaneous changes -Itching, dull pain with standing -Ulcerations just above the ankle -Skin is shiny, thin and atrophic with dark pigment changes -medial malleolous- more likely to have weeping lesions -swelling
59
chronic venous insufficiency tx
-Elevation of legs -Avoid extended sitting or standing -Compression stockings (NOT arterial -> you would compress arteries -Surgical treatment: Ligation or stripping
60
superior venal caval obstruction
Definition: -Partial or complete obstruction of the SVC usually secondary to neoplastic or inflammatory process in the superior mediastinum - MC: lung cancer obstruction SX: -Swelling of the neck, face and upper extremities - Dilated veins over the upper chest and neck -Bending over or lying down accentuates the symptoms Dx: -CT Tx: -treat underlying cause - possible stenting
61
deep venous thrombosis (DVT) typical location and what are the major risk factors
MC: Lower extremities and pelvis Virchow’s triad: major DVT risk factors -venous stasis: bed rest, long distance air travel -injury to vessel wall: surgery, trauma -HYPERCOAGULABILITY: use of oral contraceptives, hormone therapy, cancer and and inherited coagulopathy, lupus, IBD other Risk factors: -age - obesity - long distance air travel - multiparity: multiple pregnancies - IBD - lupus erythematosus
62
acute mesenteric vein occlusion presentatio
Presentation: -Post prandial pain: pain after eating - pt has evidence of HYPERCOAGULABLE state -Presents similar to arterial occlusive syndromes however is less common -clotted off part of portal circulation: mesenteric vein clot impairs blood flow from intestines to the liver!
63
acute mesenteric vein occlusion risk factors
-Paroxsymal nocturnal hemoglobinuria -Protein C, Protein S, and Antithrombin deficiencies - JAK2 mutation hypercoagulable states!!!!!
64
CT Angiography CI
renal insufficiency: contrast is processed in kidneys
65
acute mesenteric vein occlusion tx
-Thrombolysis is mainstay therapy** -Aggressive long-term anticoagulation
66
DVT sx + dx + tx
Sx: - 50% = asymptomatic - Swelling of area with erythema and warmth Dx: - Duplex US - elevated D-Dimer: Suggestive, not diagnostic; Sensitive but not specific Tx: - Anticoagulants - prevent with compression devices for bedridden pts - Heparin - novel anticoagulants
67
If PE is suspected...
CT Angiography and VQ scan

Cardiology (6 decks)

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