Signs of vascular insufficiency on exam
Hairless shiny skin, change in skin color (mottled, blanching, reddened), nail changes, ulcers or gangrene (particularly on malleoli and toes). Reproducible claudication pain (typically of calf muscles). If rest pain (burning, constant, often of forefoot), means severe ischemia.
Posterior tibial pulse
Scoring of pulses
0 = none, 1 = trace, 2 = normal, 3 = normal and strong, 4 = hyperdynamic
In what cases might your ankle-brachial index reading be misleading?
Diabetic patients (calcification of vessels makes them less compressible, falsely elevating reading), collateral flow can mask as well
Earliest sign of acute arterial insufficiency in LE
Peroneal nerve: hypesthesia along distribution, foot drop, inability to dorsiflex great toe. NB: nerves are most sensitive to ischemia, before muscles.
Causes of acute arterial occlusion
Embolism most common (A fib, s/p MI, DVT+PFO), trauma, iatrogenic (e.g. catheter related), thombosis
Treatment of acute arterial occlusion
Thrombectomy or grafting. Thrombolytic therapy (via catheter) only if ischemia not severe, as this takes time to dissolve.
Chronic ischemia involving aortoiliac vessels can present how?
Claudication, impotence, decreased or absent femoral pulses
Subclavian steal disease
Nonhemispheric cerebrovascular sx with mild arm claudication due to decreased flow to posterior cerebral artery when blood flows retrograde through vertebral artery to subclavian artery. Caused by subclavian artery stenosis.
Cut off for below the knee amputation (BKA)
Up to the malleolus. If above that need to do above the knee amputation at the least
What is the most common type of aneurysm?
Degenerative, caused by atherosclerosis- intima is replaced by fibrin.
Other types of aneurysms
Traumatic, post-stenotic (e.g. distal to aortic coarctation), dissecting, mycotic (infected), s/p anastomotic
Risk factors for dissecting aneurysm
HTN, Marfan, Ehlers-Danlos, blunt trauma, cystic medial necrosis
Complications of AAA repair
Renal failure (ATN or atheroemboli), ischemic colitis (must do immediate sigmoidoscopy to eval if resection is needed), spinal cord ichemia (artery of Adamkiewicz disrupted)
Abdominal pain, syncope, hypotension in pt with hx of AAA. 90% mortality!
For fun, what does TED stand for?
Most common presentation of DVT?
Asx! 2/3 are asx
A vasodilator that can be used to dilate the mesenteric vascular bed in a case of low-flow (non-occlusive) mesenteric ischemia
When is AAA elective repair indicated?
Greater than or equal to 5.5 cm (male) or 5 cm (female) if patient can tolerate procedure
Screening for AAA
All male smokers, once by U/S, age 65-75
TIA involving aphasia most likely stems from what?
LEFT carotid atherosclerosis
(in majority of right handed people, language is left brain)
How can you have intact pulses during compartment syndrome?
Tissue ischemia is a result of obstruction of capillary blood flow from increased tissue pressure 2/2 edema. Tissue pressure > capillary pressure but not > arterial pressure so pulses intact.
What is the most common location for occlusive disease of the LE?
Superficial femoral artery --> will affect the popliteal and pedal pulses.
If femoral pulse is affected, significant aortoiliac disease may also be present.
What is the most likely cause of death in a patient with PVD?
PVD usually means diffuse atherosclerotic disease, so most likely cause of death is coronary artery disease
How does distal claudication management differ from management of aortoiliac disease?
Distal claudication alone is usually managed well with lifestyle changes, and only intervene if really severe (rest pain, ulcers) or keeping patient from exercising (and patient can tolerate intervention). Aortoiliac disease is more likely to progress and is treated more aggressively- don't wait for rest pain/ulceration to develop.
AAA graft infection
Most commonly from contamination from skin flora (Staph epi or Staph aureus, incl MRSA). May not present for months to years. Tx: remove graft, debride, revascularize with extra-anatomic bypass, long term abx.
Upper GI bleed following AAA repair?
Could be due to aortoenteric fistula develping over time between graft and distal duodenum. Can be difficult to see on endoscopy. Tx: removal of graft, extra-anatomic bypass, repair of GI tract
What is phlegmasia cerulea dolens?
A uncommon severe form of DVT which results from extensive thrombotic occlusion of the major and collateral veins of an extremity. It is characterized by sudden severe pain, swelling, cyanosis and edema of the affected limb. There is a high risk of massive PE, even under anticoagulation. Foot gangrene may also occur. An underlying malignancy is found in 50% of cases.