ACCSAP Vascular Flashcards
What is presentation/physiology of May Thurner syndrome?
liofemoral DVT due to an anatomical variant in which the right common iliac artery overlies and compresses the left common iliac vein against the lumbar spine. This variant has been shown to be present in >20% of the population and so should be considered in the differential diagnosis of DVT, particularly in patients with other risk factors (left rather than right lower extremity DVTs, scoliosis, female sex, and oral contraceptive use or recent pregnancy).
What is classic presentation for thromboangiitis obliterans (Buerger’s disease)
Ischemia of the digits (including ischemic ulcers) is the most common presentation. Patients may also have discoloration of the hands (Raynaud phenomenon), especially during cold weather. The condition may sometimes progress so that it affects larger arteries, leading to symptoms of claudication, as seen in this patient. Smoking cessation is the only treatment.
Define critical limb ischemia
Critical limb ischemia (CLI) is a condition characterized by chronic (>2 week) ischemic rest pain, nonhealing wound/ulcers, or gangrene in one or both legs attributable to objectively proven arterial occlusive disease.
- Patients with ABI ≤0.90 are diagnosed with PAD.
- ABI 0.91-0.99 may possibly have PAD and should undergo exercise ABI if the clinical suspicion of PAD is significant. Exercise ABI can differentiate claudication from pseudoclaudication in individuals with exertional leg symptoms.
- ABI values >1.40 indicate that the arteries are not able to be compressed, which is more common among individuals with diabetes mellitus and/or advanced chronic kidney disease. Toe-brachial index (TBI) is a noninvasive test that is useful to evaluate for PAD in patents with noncompressible arteries, which cause an artificial elevation of the ABI.
Carotid endarterectomy is recommended for significant symptomatic carotid stenosis, defined as stenosis >__% by ultrasound.
70%
Which of the following is the most appropriate antiplatelet strategy for secondary prevention of ischemic stroke? (old lacunar infarct, no other obvious clinical cause)
Plavix!!
Not aspirin (could use aggrenox = asa + dipyridamole, but has higher bleeding than palvix)
58M with stable claudication - which of the following is this patient most likely to experience in the next 5 years? A. Amputation. B. Ruptured aortic aneurysm. C. Hemodialysis. D. Myocardial infarction. E. Limb revascularization.
Myocardial infarction!!
25-30% all-cause 5-year mortality and 20% 5-year cardiovascular mortality among patients with PAD and claudication. An additional 20% of PAD patients will have nonfatal myocardial infarction (MI) or nonfatal stroke in the same 5 years of follow-up.
Limb-specific outcomes are less common than cardiovascular outcomes in patients with PAD and claudication: >70% of patients will have stable claudication at 5-year follow-up, 16% will have progressive claudication, 7% will require surgical revascularization, and <5% will require amputation.
What are the BP goals in ischemic stroke patients treated WITH, and
WITHOUT thrombolytics?
<185/110 if treated with thrombolytics
<220/120 if no lytics, and no other comorbid issues (dissection, eclampsia, unstable ACS, etc)
What is the correct way to calculate ABI when there are different SBPs in the upper extremities?
The ABI is calculated as the ratio of blood pressure in the leg to the arm blood pressure. Patients with peripheral arterial disease (PAD) frequently have subclavian stenoses causing a difference in arm blood pressures; in this situation, the higher blood pressure should be used for calculating the ABI.
When would screening with carotid US be reasonable prior to CABG?
Carotid duplex ultrasound screening is reasonable before CABG in patients >65 years of age and in those with left main coronary artery stenosis, peripheral artery disease (PAD), history of smoking, history of stroke/transient ischemic attack, or carotid bruit.
What is the correct fixed dose of PCC for any bleed, and for an intracranial bleed if a person is on warfarin/needs reversal?
a fixed dose can be given with 1000 units for any bleed and 1500 units for intracranial bleed;
What gene abnormality is present in Marfan Syndrome.
What is prevalence?
1 in approximately 5,000 individuals, is an autosomal-dominant connective-tissue disorder due to mutations in the gene encoding fibrillin-1 (FBN1)
What is the indication for aortic root repair in Marfan syndrome?
external diameter of 5 cm. Factors that will prompt repair at a diameter <5 cm include rapid growth of >0.5 cm in 1 year, family history of aortic dissection at a diameter <5 cm, or the presence of significant aortic regurgitation.
What are some drugs known to worsen Raynaud’s phenomenon?
Drugs that enhance vasoconstriction include beta-blockers, clonidine, ergot alkaloids, and dopaminergic alkaloids such as bromocriptine, sympathomimetics, stimulants, and cyclosporine.
Treatment for critical limb ischemia includes?
Revascularization OR thrombolysis?
Revascularization. Thrombolysis for CLI is IIb recommendation.
Clinical trials have not demonstrated an advantage to surgical versus endovascular approaches.
Describe the classic presentation for Buerger’s disease (thromboangiitis obliterans).
Ischemia of the digits (including ischemic ulcers) is the most common presentation. Patients may also have Raynaud’s phenomenon changes with discoloration of digits in cold weather, as well as an abnormal Allen test on examination. Smoking cessation is the only proven treatment for Buerger’s disease. Whereas high-intensity statin therapy, regular exercise, and improved BP/glucose control have benefits for other cardiovascular conditions, they have not been shown to improve Buerger’s disease.
