07 Vascular Flashcards
A 54-year-old right handed laborer notices coldness and tingling in his left hand as well as pain in the forearm when he does strenuous work. What really concerned him, though, is that in the last few episodes he also experienced transitory vertigo, blurred vision, and difficulty articulating his speech.
Subclavian steal syndrome. A combination of claudication of the arm with posterior brain neurologic symptoms is classic for this rare but fascinating (and thus favorite question) condition.
Management. Duplex scanning will demonstrate retrograde flow through the vertebral artery when the patient exercises the arm. Surgical bypass resolves the problem.
A 62-year-old man is found on physical examination to have a 6-cm pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus.
What is it? An abdominal aortic aneurysm.
Management. He needs elective surgical repair, but because our decisions are based so much on the size of the aneurysm, we need more precise measurement. A CT scan is indicated.
- A 62-year-old man has vague, poorly described epigastric and upper back discomfort. He is found on physical examination to have a 6-cm pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus. The mass is tender to palpation.
What is it? An abdominal aortic aneurysm that is beginning to leak.
Management. Get a consultation with the vascular surgeons today.
A 68-year-old man is brought to the ER with excruciating back pain that began suddenly 45 minutes ago. He is diaphoretic and has a systolic blood pressure of 90. There is an 8-cm, pulsatile mass palpable deep in the abdomen, above the umbilicus.
The aneurysm is rupturing right now. He needs immediate, emergency surgery.
A wealthy, retired man has claudication when walking more than 15 blocks.
Vascular surgery and angioplastic stenting are palliative procedures. They do not cure arteriosclerotic disease. Claudication has an unpredictable course; thus, there is no indication for early operation or intervention. No expensive workup is needed. If he smokes, he should quit, and he would benefit from a program of exercise and the use of cilostazol.
A 56-year-old postman describes severe pain in his right calf when he walks two or three blocks. The pain is relieved by resting 10 or 15 minutes, but recurs if he walks again the same distance. He cannot do his job this way, and he does not qualify yet for retirement, so he is most anxious to have this problem resolved. He does not smoke.
Management. This fellow needs help. Start with Doppler studies. If he has a significant gradient, CT angio or MRI angio comes next, followed by bypass surgery or stenting.
A patient consults you because he “cannot sleep.” On questioning it turns out that he has pain in the right calf, which keeps him from falling asleep. He relates that the pain goes away if he sits by the side of the bed and dangles the leg. His wife adds that she has watched him do that, and she has noticed that the leg, which was very pale when he was lying down, becomes deep purple several minutes after he is sitting up. On physical examination the skin of that leg is shiny, there is no hair, and there are no palpable peripheral pulses.
Rest pain. Definitely he needs the studies to see whether vascular surgery could help him.
A 45-year-old man shows up in the ER with a pale, cold, pulseless, paresthetic, painful, and paralytic lower extremity. The process began suddenly 2 hours
ago. Physical examination shows no pulses anywhere in that lower extremity. Pulse at the wrist is 95/min, grossly irregular.
What is it? Embolization by the broken-off tail of a clot from the left atrium. Start with Doppler studies. If he has complete occlusion, do embolectomy with Fogarty catheters, and if he was ischemic for several hours, add a fasciotomy to prevent compartment syndrome. Incomplete occlusion may be treated with clot busters.
A 74-year-old man has sudden onset of extremely severe, tearing chest pain that radiates to the back and migrates down shortly after its onset. His blood pressure is 220 over 110, and he has unequal pulses in the upper extremities and a wide mediastinum on chest x-ray. ECG and cardiac enzymes are negative for MI.
What is it? Dissecting aneurysm of the thoracic aorta.
Management. Spiral CT scan is the best study to confirm the diagnosis in a noninvasive way. If the aneurysm is in the ascending aorta, emergency surgery should be performed. If it is in the descending aorta, intensive therapy in the ICU for the hypertension is the preferable option.
