4 - Vascular Flashcards
Anatomy review: artery
Intima - endothelium that lines the lumen of all vessels
Media - smooth muscle, elastic fibers
Adventitia - collagen fibers
What is an aneurysm?
Local dilation of an artery
MC cause of arterial aneurysm?
Atherosclerosis (95%)
HTN
Describe AAA
The guys you call when your car breaks down . . . . . . . . . Also, a pulsatile mass on the anterior abdomen, often asymptomatic and found on routine exam
What do you wanna avoid with AAA?
Manipulation - you could cause shower emboli
If the abdominal aorta is TTP:
Refer immediately
Plain films of an aneurysm may show:
Calcification
Best study for following the size of a AAA?
US
Study fro dx’ing aneurysmal rupture?
CT
When is aortogram usually done?
Prior to a scheduled procedure
3 subtypes of pseudo-aneurysm?
- Saccular - discrete outpouching
- Fusiform - diffuse
- Mycotic-associated with infection
MCC of pseudo-aneurysm?
Trauma
MCC of mycotic aneurysm?
Syphilis
Factors that increase risk of rupture of AAA:
>6cm Rapid expansion (>0.6cm/yr) Female>male Saccular>fusiform Smoking HTN COPD Steroid use Family Hx
When to do surgical repair of AAA?
- If symptomatic - emergent
- Rapid expansion
If asymptomatic but >5.5cm, elective surgical repair
Sxs of rupture:
Flank, back or abd pain
Tenderness to palpation
Flank ecchymosis (Gray-Turner)
HOTN
Decreased femoral pulse
Types of AAA repairs:
Open - really risky, but if rupture, gotta do it
Endovascular stent - safer
Complications of AAA
Infection -> mycotic aneurysm
Fistula:
IVC -> CHF
GI tract -> aorto-enteric fistula (GI bleed)
Blue Toe Syndrome?
Distal embolization
Mural emboli and plaques -> small clots
Impaired blood supply to toes
Causes of thoracic aneurysm?
Aortic dissection Marfan’s Infx Trauma Associated with but not caused by atherosclerosis
MCC of aortic transection
MVA’s
Prognosis for aortic transection?
80% die at the scene
Most reliable test for aortic transection?
CTA
Preferred repair of aortic transection
Delayed repair preferred to allow for BP control (make pt hemodynamically stable)
MC catastrophic event involving the aorta?
Aortic dissection
Brittle aortic wall, destruction of arterial media, loss of elastic fibers, intima tear
Stanford:
Any proximal involvement - “A”
Distal involvement “B”
Presentation of dissection
Older men Sharp, sudden, tearing chest/back pain Hx of HTN FHx Pulse difference between arms Diastolic murmur Pulmonary edema Signs of CVA if carotid involved
W/U for aortic dissection
R/O MI/PE first
Imaging - CXR c widened mediastinum, pulm. edema, pleural effusion
CT
TEE
96% of aortic dissections had which three findings?
Abrupt onset tearing/ripping pain
Pulse deficit or BP difference > 20
Widened mediastinum on CXR
Management of aortic dissection
BB’s THEN vasodilators
Ascending - surgical
Descending - medical
3 causes of carotid-related CVA:
- Embolization (MC)
- Thrombosis from a-fib
- Flow-related brain ischemia
Sxs of carotid artery dz
Many asymptomatic
TIA (hemiparesis, slurred speech, amarurosis fugax)
Diagnosis of carotid artery dz
Duplex US - luminal diameter and blood flow
CT head
MRI/MRA - better for ischemic CVA
Echo - rule out cardiac source
Carotid angiogram - GOLD STANDARD
Medical management of carotid artery dz
Stop smoking
ASA 81mg PO QD
Serial duplex scans
Surgical management of carotid artery dz
Carotid endarterectomy
Carotid stent
Subclavian steal syndrome
Narrow subclavian artery
Use of arm causes early fatigue
Subclavian “steals” blood from the vertebral artery
Causes brain ischemia (light-headedness)
Acute Mesenteric ischemia will look like:
Pain out of proportion
Severe/diffuse ABD pain
Can lead to peritonitis if bowel becomes necrotic
Chronic mesenteric ischemia will look like
Food fear - post-prandial ABD pain
Weight loss
N/V/D
Risk factors for atherosclerotic peripheral vascular dz
Smoking HTN DM Dyslipidemia Known vascular dz
Sxs of PVD
Intermittent claudication
PE for PVD
Femoral bruit Decreased ABI Decreased pedal pulses Decreased hair Shiny / brittle skin Muscle atrophy Impaired wound healing Pallor in elevation Ischemic ulceration
Dx of PVD
H and P
Measure ABI
US with doppler
CTA
Management of PVD
Stop smoking Eat better Exercise Be nicer to the homeless Take your statins and ASA
Late management of PVD
Stents
Bypass / grafting
Goals - prevent limb loss and avoid disability
Popliteal artery entrapment
Abnormal insertion of gastroc
Medial deviation of artery
Ischemia with exercise
Intermittent claudication
Asymptomatic at rest
Thromboangitiis obliterans
AKA Buerger’s Dz
Young smokers
AI component
Foot claudication
Excruciating ischemic pain
Goes away if you stop smoking
Causes of acute arterial occlusion
Emboli
Chronic PVD
Trauma (long-bone fx)
5 P’s
Pain out of proportion Pallor Paresthesia Pulseless Paralysis
Hard signs of arterial injury
Pulsatile bleed Expanding hematoma Bruit / thrill Pulseless / cool extremity Sensory deficit
Txt for arterial occlusion
Anticoagulate c heparin
Arteriogram
Trauma - repair
Transected artery
Penetrating wounds
Deep lacs
Partial amputations
Arterial stump can retract with clot
Absent distal pulses
Distal ischemia
Problem c lacerated pseudoaneurysm?
Can’t retract / spasm / constrict
AV fistula
Communication between artery and vein
Thrill over the anastomose site
Repair c vascular surgery
Used in dialysis
Arterial stress injuries
Anterior dislocation of knee
Sonic injury from bullet
Internal disruption of intima with thrombosis
Contained injury, no bleeding
May still have distal perfusion from collateral vessel
Urgent managemment
Penetrating injuries management
Can observe if:
No hard signs
No fx
ABI > 0.9
If above criteria not met, must get imaging - CTA, arteriogram, US
Every girl is a squirter
If you hit an artery
