248. Limb Vasculature

Question 1

Thoracic Outlet Syndrome Mechanisms, Dx Test, types

Answer 1

Roos Test: Goal post arms, open/close fists for 2 min - provoke blood flow alterations - see if sx occur

Anatomy: Subcoracoid space or in interscalene triangle
Mechanisms: trauma, repetitive motion (muscle hypertrophy), extra cervical rib, tumor/large lymph nodes, whiplast injury to back/neck, poor posture

Neurogenic v. Venous v. Arterial

Question 2

Neurogenic TOS

Prevalence, Epidemiology, Sx

Answer 2

MOST COMMON TOS (95%)
Usually bilateral with normal neuro exam
All ages, F>M
Sx: upper limb parasthesia, trapezius/neck/shoulder/arm pain, supraclavicular pain, occipital headache, chest pain

Question 3

Venous TOS

Prevalence, Epidemiology, Presentation

Answer 3

2nd Most Common (3-5%)
Physically Active, 15-45y/o, M>F
Unilateral on dominant upper extremity
Subclavian vein compression + repetitive injury
Paget-Schroetter Disease: Effort thrombosis following strenuous repeated arm activity
Present: unilateral arm swelling, cyanosis, heaviness, pain, 10-20% pulm embolism risk

Question 4

Arterial TOS

Prevalence, Epidemiology, Presentation

Answer 4

Most Rare (1-2%)
M=F, young adults
Unilateral subclavian artery compression due to anomalous cervical rib/physically active entrapment
Arterial Thrombosis and DISTAL embolization = distal upper extremity ischemia

Question 5

Testing and Tx for TOS

Answer 5

Imaging: XR of C-spine, CT, Venous Doppler, Angiogram, EMG for nerve damage

Tx: PT, posture, surgery if neuro dysfx or vascular ischemia

Question 6

Deep Vein Thrombosis

Presentation, Risk Factors, Tx, Complication

Answer 6

P: pain/throbbing, leg edema, redness/warmth, pain walking, asx
RF: Hypercoagulable state - surgery, hospitalization, pregnancy, reduced mortality, active cancer
Tx: anticoagulation
C: Pulm embolism (acute), post-thrombotic syndrome/venous ulceration (chronic)

Question 7

Backer’s (Popliteal) Cyst

what it is, presentation, tx/prognosis, complication

Answer 7

Fluid filled distention of preexisting bursa in medial popliteal fossa - one way valve if effusion present = cyst formation
P: assoc with intraarticular pathologies, asx/rupture without knee pain, older age, best seen on MRI
Tx: leg edema resolves, analgesics for sx, inject bursa with glucocorticoids
C: ruptured cyst = high risk of popliteal artery/vein compression (ischemia/thrombosis) - like DVT, tibial/fibular nerve compression

Question 8

Popliteal Artery Entrapment

Epidemiology, Cause, Test, Tx

Answer 8

Young Athletic pt with intermittent calf/foot claudication (NO pain at rest)
Cause: Anatomic (abnormal muscle artery arrangement), Functional (muscle hypertrophy)
Tests: Ankle-Brachial Index (Ankle BP/Arm BP < 0.9 is abnormal
Tx: surgery if pervasive sx

Question 9

Atherosclerosis

Types, Test, Tx

Answer 9

1. PAD - assoc with smoking, ischemic heart disease; test with ABI <0.9 at rest (fixed compression), tx: modify risk factors, exercise, surgery if severe
2. SLE - assoc with CV disease in young women, strongest risk factor for CV disease, systemic inflammation and direct vascular damage, higher prevalence of CV risk factors!