Aortic and Peripheral Vascular Disease Flashcards
Aortic Dimensions
root
ascending
arch
decending
root: widest: 2.5 to 3.5 cm
ascending: 2.5-3.5
arch: 2.5-3.5
decending: 2-3
what is an aneurysm
- where can they occur
- types (4)
- a ballooning or focal dilation of the vessel due toa weakening in the wall
- this ballooning is of ALL layers of the vessel
- can lead to rupture or dissection: emergency
where
- aorta: abdomnical v thoracic
- brain
- neck
- intestines, kidneys, spleen
- legs
Types
- asymptomaic: we dont know you have it and neither do you
- dissecting: aneuryseum with dilation that is starting to TEAR the wall of the vessel
-
- pseudoanryseum: no real enlargement of the layers of the blood vessel can be due to outside force or trauma (like after a line has been placed) could be ballooning of just one layer (like externa)
Aortic Dissection
- what is it
- where does it occur
- patho
- risk factors
TEARING of the innermost layer of the aorta
- most commonly at the acending aorta: highest mortality rate
Patho
- long standing risk factors
- damage to the tunica intima
- a tear in the lining of the intmia
- high pressure in aorta: leads to further tearing of the intmia
- blood starts forcing into the tear – gets stuck in between the intima and media
- reduces flow out to the body then – get systemic symptoms
- with time, tear through all layers, and death
Risk Factors
- HYPERTENSION!!!! uncontrolled, long time, 80% of cases
- age: 50-60 year old males
- marfans ! can appear younger
- atherosclerosis: hardening of the wall lost compliance
- tobacco use
- drugs
- family history!!
- marfans or ehlers danlos
- vasculitis
- trauma
- turner syndrome
Aortic Dissection
- clinical manifestion
- diagnosis
- treatment
classifications
Clinical Manifestation
- CHEST PAIN THAT IS RIPPING, TEARING and KNIFELIKE
- can radiate to back or scapula
- nausea, vomiting, sob, sweting, jaw pain, syncope
on exam…
- sweating, pale
- HTN, tachycardia
- decreased peripheral pulses
- pulse Variation > 20 mmHg difference
- new murmurs: aortic regurg, diastolic decrecendo
Diagnosis
- GOLD STANDARD: MRI with angio but not if unstable
- CT chest with contrast can be done quickly and first
- CXR: widened mediastinum
- TEE: if stable
Debakey and Standford Classifications
STANFORD: A- if the acending aorta is involved at all
B- if the decending aorta is only involved
De Bakey: Type 1: acending and decending
type 2: acending only
Type 3: decending only
Treatment: depends where and if stable
treat with medication if… Decending aorta only and stable – debakey III , Standford B
- BETA BLOCKERS: esmolol, labetolol –> SBP < 100-120 and pulse < 60
- then can use nitroprusside, nicardipine
treat with surgical intervention… if Acending aorta involved (AT ALL!) or if theyre hemodynamically unstable …. Debakey I, II or Standford A
- open heart
- endovascualr repair to patch or stent
Abdominal Aorta Aneurysm (AAA)
- what is it
- patho
- risk factors
- clinical signs
- diagnosis
- treatment
focal dilation of the aorta at the level of the RENAL ARTERIES
- most commonly occurring infrarenally
- 1-1.5x the diameter of the renal arteries —- > 3 cm is one!!
Patho
- some injury, inflammation (unknown) triggers degrading cell wall matrix (media), smooth muscle becomes damanged
- lost integritiy of the wall – anyuresum
Risk factors
- ATHEROSCLEROSIS: imapcting the integritiy of teh wall
- smoking and tobacco use!!!! MAJOR factor
- MALES: 5x more common
- hyperlipidemia, HTN, marfans too
Clinical signs
- asymptomatic until rupture or dissection occurs
if dissection….
- severe back/abdomen pain
- syncope
- hypotension
- pulsitile mass
Diagnosis
- GOLD STANDARD: ANGIOGRAPHY MRI
- FIRST CHOICE: US of abdomen initial choice
- Ct with contrast can be done
Treatment
- determined by size….
- > 5.5 cm or expanding > .5 in 6 months = surgery asap
- 4-5.5 - referral to surgery
- 4-4.5 Q6 monitor
- 3-4 yearly monitor
- srugery is only fix
- BBlockers can help
- lifestyle modifications
common types of peripheral venous disease (3)
DVT
Varicose Veins
Chronic Venous Insufficiency
Arterial Insufficency (PAD)
DVT
- causes
- clinical manifestations
- risk factors
- workup
- treatment
length of treatment
deep venous thrombosis
- a thrombus (clot) formation in the deep veins – most commonly the legs
Risk Factors
- VRICHOWS TRIAD: statsis, wall injury and hypercoaguable state
- previous DVT
- recent surgery, trauma
- increased age
- pregnant, OCP use
- recent travel
- medical conditions of hypercoag. (FActor 5, protein C/S def.)
Clinical Manifestation
- unlilateral swelling/edema of extermitiy >3cm difference between the two
- tender/pain
- warm, red
- palpable cord
- + homanns
- cerulea alba: pallor milky white LE (because occuled)
- cerulea dolens: cyansosi, swlling and sudden pain of LE
Workup
- thorough history!!!!
- wells criteria – 3+ high risk, 1-2 moderate risk
- if WELLS is + –> d-dimer or US to rule in or out
- D-Dimer: fibrin degrading – not specific (other things increase D dimer) – seems like this happens before US
- US: first line imaging
- VENOGRAPHY is gold standard
Treatment
- want to prevent PE: anti-coag.
- anti-coag: heparin, warfin or DOAC
- unfractionated heparin: monitor PTT, ok in renal failure
- LMWH: no PTT monitoring, cant use if Cr < 2
- warfarin: monitor PT/INR , vit K
- DOAC: apixaban, rivaroxaban choose this over warfarin
- IVC filter if cant anticoag.
length of treatment
- first event: known cause and reversible: 3-6 months
- first event: dont know why longterm if PE, 3-6 months if distal
- distal DVT with no symptoms: no treatment; just serial monitoring of the DVT
- DVT + pregnant: LMWH
- DVT + cancer: LMWH
Varicose Veins
- patho
- causes
- clinical signs
- management
dilated, tortuous veins superfiscal usually in LE
- due to defective valves!!! – saphenous veins MC
Patho
- weak vessel wall – increased pressure – reversal of flow through valves – get varicose
Causes
- estrogen
- prolonged stadning
- obestiy
- older age
Clinical
- asymptomatic; cosmetic
- dull, achy pressure with standinng
- venous statsis and ulcers
managemetn
- leg elevation, compressions
- sclerotherapy, laser
Chronic Venous Insufficiency
- patho
- etiology
- clinical signs
- treatment
- incompetiency of the deep or superfiscial veins
patho
- vales norammly ensure blood flow goes back to the heat
- valves get damanged: blood flows backwards and pools in veins
etiology
- chronic DVT, thrombophlebitis, trauma
clinical signs
- burning, aching heavy legs
- edema
- stasis dermatits: exzematous rash: itchy scaling bronw hyperpigmentation with pooling of blood weeping erosions and medial malleollous
Diagnosis & Treatment
- trendelenburg test: competency of veins or US
- compressions are mainstay treatment
- lifestyle cahnges, ulcer management
Peripheral Arterial Disease (Arterial Insufficiency)
- patho
- clincial signs
- diagnosis
- treatment
atherosclerosis outside heart and brain = MC in LE
Clinical Signs
- intermittent claudication pain with movement
- resting pain: ischemia!!!
- 6 Ps: pain, pallor, parestheisas, pulselessness, parylasis, polikiothermia
- gangre: from poor perfusion to necrosis
- pale, cool, shiny skin
- absent or diminished pulses (bruits!!)
- lateral malleolous ulcers
- rubor (dusky red skin)
Diagnosis
- gold standard: arteriography
- ABI index score helpful too (normal is 1-1.2)
- US too
Treatment
- first line: platlet inhibitors: Cilostazol vasodialtes and antiplatlet
- asprin
- clopidigrel too (anti-platelet)
- revascualrization possible angioplasty and stent in legs
Mesenteric Ischemia
acute
-patho
exam
diagnosis and treatment
- sudden, decrease or obstruction of blood flood to GI – splenic flexture
Patho
- most commonly due to acute occulation
- thrown clot: emboli from afib or thombus from atherosclerosis
clincial signs
- severe abdomincal pain out of proportion to how they look
- not localized
- N/V/D
Diagnosis
- angiogram is test of choice
- initally: CT can show
- colonoscopy can help too
treament
- surgical revascularization, stent and bypass
- medications
- antiplatlets, anticoags, statins
Mesenteric Ischemia
Chronic
- patho
- clinical signs
- diagnosis
- treatment
patho
- due to chronic ischemic of atherosclerosis
clinical signs
-DULL abdomnial pain
- worse after eating
- weight loss
Diagnosis
angiogram
MAnagement
- bowel rest, diet changes
- surgical revasculaization
- medications **antiplatletns, anticaogs and statin
Arterial Embolism/ Limb Ischemia
- patho
- clinical
- treatment
patho
- piece of plaque, or blood clot travels to the body other spot and occludes the vessel – often in the LE
- lost flow to the point
clinical
- mottling of skin
- pain, pallor, pulseness, paresthesias, parlysis, polkilothermia
treament
- emergency revascualr to remove clot
Thrombopphlebitis
- patho
- causes
- diagnosis nad treatment
inflammation or thrombus of vein superficially
patho
- superfisicaul inflammation of a vein leads to thrombus – self resolves
causes
- IV
- trauma
- pregnant
- varicose veins
Diagnosis: clinical or US
Treatment: supportive, elevation , NSAIDS, warm compresses
