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Arterial Disease Flashcards

1
Q

what imaging do we use to check for aortic aneurism?

A

MRI or CT

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2
Q

what are the layers of the aorta?

A

Tunica Intima (innermost)
Tunica media
Tunica adventitia (outermost)

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3
Q

Aneurysm definition

A

Dilatation of the aorta ( > 3cm)

Involves all 3 layers of vessel wall

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4
Q

conditions of heart

Dissection

A

Tear of the tunica intima creates a false lumen

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5
Q

conditions of the heart

Rupture

A

Full-thickness tear of aorta

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6
Q

Abdominal Aortic Aneurysm
Epidemiology

A

2% of men over 55 years old
Male > female (4:1)
90% originate below renal arteries
Involvement of the aortic bifurcation
May involve common iliac arteries

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7
Q

Abdominal Aortic Aneurysm

Risk Factors

A

Advanced age
Male sex
Tobacco use
Alcohol use
White population
Family history
Atherosclerotic risk factors
Hypertension
Hyperlipidemia

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8
Q

who is at the highest risk of abd aortic aneurysm?

A

white elderly men with a history of tobacco use and atherosclerotic risk factors

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9
Q

abd aortic aneurysm

Sx

A

Asymptomatic
Incidental finding on abdominal ultrasound or CT imaging

Symptomatic – Sign of rapid expansion or impending rupture
Mild to severe deep abdominal or flank pain that is constant or intermittent
Exacerbated upon palpation
Pain radiates to back

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10
Q

abd aortic aneurysm

complications

A

rupture - very poor prognosis

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11
Q

abd aortic aneurysm

imaging of choice

A

Abdominal Ultrasound
Diagnostic study of choice for initial screening

Abdominal CT with contrast
Assess diameter
Surgical planning

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12
Q

58 yo male PMHX: HTN, HLP, and tobacco presents for routine OV and has a pulsatile abdominal mass. Which test is indicated at this time?
Abdominal ultrasound
CT angiogram
MRA
TEE

A

Abdominal ultrasound

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13
Q

Abdominal Aortic Aneurysm

Surgical Repair indications

A

Diameter > 5.5 cm
Rapid expansion in diameter (> 0.5 cm in 6 months)

Symptomatic – Pain, tenderness
May indicate impending rupture

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14
Q

what diseases make you more prone?

A

marfans and Ehlers-Danlos syndrome

not testable

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15
Q

abd aortic aneurysm

complications of open repair and endovascular repair

A

Open repair carries more intraoperative risk, while endovascular repair has higher incidence of post-operative complications

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16
Q

A 55 yo patient presents to pcp for routine yearly exam. + tobacco abuse. 148/90. What screening test is NOT indicated?
a.Lipid panel
b.ECG
c.Abdominal aortic ultrasound
d.Coronary artery calcium score
e.cxray

A

D. only need if deciding they need statin, but knowing that they are smoker and over 55 with high BP we know they need a statin

(goal bp is 130/80)

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17
Q

Thoracic Aortic Aneurysm

Etiology and Risk Factors

A

Idiopathic/Degenerative
Atherosclerosis
Hypertension
Smoking
Aortitis
Takayasu arteritis
Giant cell arteritis
Connective tissue disorders
Marfan syndrome
Ehlers-Danlos syndrome
Bicuspid aortic valve
Family history of TAA

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18
Q

Thoracic Aortic Aneurysm

Sx

A

Asymptomatic
Symptoms dependent upon size and position of the aneurysm and rate of growth
Esophagus – dysphagia
Trachea – stridor, dyspnea
Superior vena cava – Upper extremity edema, jugular venous distension
Aortic root – Aortic regurgitation
Substernal chest pain
Pain radiating to the back or neck
Complications
Rupture

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19
Q

Thoracic Aortic Aneurysm

Imaging

A

Chest radiographs
Useful initial evaluation
Not sensitive or specific

CT Angiography
Best initial imaging for patients suspected to have TAA

Transesophageal or transthoracic echocardiogram
Further evaluation

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20
Q

A patient presents with acute tearing scapular pain. They have a history of thoracic aortic aneurysm. BP 70/40 with HR 130. They are becoming confused. Which of the following is indicated?
A- TEE at bedside stat
B- CTA stat
C- MRA stat

A

A- is the answer

If hemodynamically unstable, dont want CT or MRA

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21
Q

Patient presents with acute chest pain, no ECG changes, and mediastinal widening on cxray…..

A

TAA

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22
Q

Thoracic Aortic Aneurysm

Surgical repair indications

A

Indications
Diameter > 5.5 cm
All symptomatic TAAs require surgical repair
Patients with genetic conditions have a lower threshold for surgical repair due to increased risk of rupture
Repair of asymptomatic TAAs is not recommended until risk of rupture exceeds risks of repair

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23
Q

TAA 5-year Risk of Rupture/Death

A
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24
Q

thoracic aortic aneurysm

What is the risk with surgically repairing a TAA

A

the more extensive the aneurysm, the greater is the risk of paraplegia with repair.

slide 25

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25
# Aortic Rupture Etiology
Blunt force trauma High-speed MVC Rapid deceleration No use of seatbelt Sequela of aortic aneurysm
26
# aortic rupture Triad
Triad: Severe pain Hypotension Pulsatile abdominal mass
27
# aortic rupture mortality
Extremely high mortality 50% patients exsanguinate before reaching a hospital Contained rupture in retroperitoneum Only 50% of patients survive post-surgery Complications Abdominal compartment syndrome
28
# Aortic rupture imaging
Thoracic: **Chest CT scan Transesophageal Echocardiogram Abdominal **Abdominal CT scan** Hemodynamically unstable: Get to the OR without delay. Intraoperative imaging vs. open exploration
29
# Aortic Rupture Management
-Endovascular Specialized surgeons and facilities Hemodynamically stable patients who have undergone CT imaging Lower perioperative mortality -Open 50% survive repair
30
Aortic Dissection definition
-Spontaneous tear of tunica intima -Blood dissects into the tunica media -Repetitive torque during cardiac cycle -**Hypertension**
31
# Aortic Dissection RF (Abnormalities)
Hypertension Abnormalities of smooth muscle, elastic tissue, or collagen *Marfan syndrome Ehlers-Danlos syndrome* Pregnancy Anatomic abnormalities *Bicuspid aortic valve* Coarctation of the aorta
32
# Aortic dissection Debakey and Stanford Classification
## Footnote dont need this
33
# Aortic Dissection Triad
Triad 1) Abrupt onset thoracic or abdominal pain with sharp, tearing, ripping character 2) Pulse and/or blood pressure variations between extremities 3) Mediastinal and aortic widening on CXR
34
# Aortic Dissection clinical man
**Sudden onset severe, persistent chest pain described as ripping, sharp, tearing** Pain radiates in respect to location and extension of dissection Down the back Anterior chest Neck **Hypertension** Syncopal episodes Diminished peripheral pulses **Variations in pulses and blood pressure when comparing extremities** Other clinical findings respective to location and extension of dissection Hemiplegia Mesenteric ischemia Acute kidney injury Myocardial infarction
35
Aortic root dissections may present with: 2 sounds, 2 diseases
Diastolic murmur Aortic regurgitation Acute heart failure Cardiac tamponade
36
when should you consider an aortic dissection?
Consider aortic dissection in hypertensive patients with chest pain and equivocal findings on ECG
37
# Aortic Dissection imaging
Electrocardiogram (ECG) Initial evaluation of patients with chest pain Absence of ECG changes (no ischemia) Chest Radiograph (x-ray) Differentiates various causes of chest pain Widening of mediastinum/aortic silhouette **CT of chest and abdomen Immediate diagnostic imaging of choice** MRI of chest and abdomen Not readily available in emergent situations Transesophageal Echocardiogram
38
# aortic dissection Management and Disposition
Labetalol (only one with meds)
39
40
Peripheral Artery Disease
Systemic atherosclerosis 30% of patients over 70-years-old with no other risk factors 30% of patients over 50-years-old with risk factors Typically in legs, muscles feel tired and heavy with activity and it improves with rest, tends to be **unilateral.**
41
# PAD RF
Coronary artery disease Increased age Hypertension Dyslipidemia Tobacco use Male sex Diabetes Metabolic syndrome Erectile dysfunction Family history of cardiovascular disease
42
# PAD Clin man
**Intermittent claudication** Cramping pain in the lower extremities Induced by activity Relieved with rest Cool skin temperature Pale skin color Scant hair distribution Weak distal pulses Nonhealing wounds
43
# PAD Complications
Complication: Chronic limb threatening ischemia -> nonhealing wounds -> gangrene
44
# PAD Dx
**CT gold standard**
45
# PAD Management Pharm(3) and non pharm(3)
Antiplatelet Therapy -Clopidogrel, Aspirin High-intensity Statin Therapy Risk factor modification- Smoking cessation, Tight glucose control, Blood pressure control
46
# PAD Surgical intervention
Endovascular Revascularization Indications: Significant pain, disability, inadequate response to treatment Critical limb ischemia Balloon angioplasty with or without stent placement Arthrectomy Bypass
47
# Chronic Limb Threatening Ischemia Clincal findings
Foot ischemic wounds Ulceration and gangrene Severe vascular insufficiency Ischemic rest pain ischemic foot wounds that dont heal, or pain in th extremity with rest, limb without pulse
48
# Chronic Limb Threatening Ischemia management
49
Acute Arterial Occlusion Causes
from thrombus or embolus Thrombus- A blood clot that develops as a result of a ruptured atherosclerotic plaque or stagnant blood flow from cardiac arrhythmia Occlusion of small, distal arteries History of peripheral artery disease Embolus- A blood clot arising from the vascular system that travels to a distal area, causing occlusion Occlusion of larger arteries History of cardiac event
50
#Acute Limb Ischemia Causes
Arterial Embolism Atrial Fibrillation- most common Valvular disease Left ventricular clot formation from myocardial infarction Acute Thrombus Pre-existing peripheral artery disease
51
# Acute Limb Ischemia clinical findings 5 p’s
Abrupt onset pain in extremity The 5 P’s Pain Pulselessness Pallor Paralysis Paresthesia Limb is cool to touch Degree of ischemia is related to collateral blood flow
52
# Acute Limb Ischemia Dx
Vascular Sonography Arterial Doppler Ultrasound CT Angiography Delayed intervention Reserved for viable ischemia
53
# Acute Limb Ischemia Tx
* Anticoagulation Unfractionated Heparin IV Clot propagation prevention Does not resolve the occlusion * Endovascular Revascularization Catheter-directed thrombolysis tPA (Tissue plasminogen activator) Clot lysis Patients with intact neurologic examination (viable limbs) * Thromboembolectomy
54
treatments for acute limb ischemia
55
A 65-year-old white man with hypertension and a 10-pack-year history of cigarette smoking should be screened for_____________. What imaging modality is used for surveillance? ___________.
abd aortic aneurysm ultrasound
56
A 76-year-old man comes to the ED with abdominal pain radiating to the back. What imaging study is indicated? ____________ (This question is tricky. Let’s talk about it).
if he's hemodynamically stable you would get a CT.
57
On physical examination, you palpate the abdominal aorta measuring 6.5 cm. The patient has no symptoms. What is your next step? ____________. Do es this patient need surgery? _________.
ultrasound yes
58
A patient is brought to the ED with ripping, stabbing chest pain. BP is 178/85 mmHg. What is your first step in diagnosis? ___________
EKG to make sure we dont have aortic aneurysm we do esophageal echo
59
On ECG, there is no ST elevation. Cardiac troponin is negative. What is ruled out? ___________
Non STEMI/STEMI
60
A 40 yo patient is brought in via EMS from MVA with airbag deployment. The patient reports chest pain and soon loses consciousness. Vs: 80/40, 130, 22. physical exam: chest has diffuse bruising and crepitus a. TEE with IVF and blood products b. TTE with IVF and blood products c. CTA with IVF and blood products d. CT with IVF and blood products e. Immediate surgical cx with IVF and blood products
E and A … If patient were more stable would obtain CTA prior to taking to OR
61
ABI
Ankle brachial index Normal:1.0-1.4 PAD: less tan or equal to 0.9 Severe disease: less than 0.5

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