Arterial Disease Flashcards
what imaging do we use to check for aortic aneurism?
MRI or CT
what are the layers of the aorta?
Tunica Intima (innermost)
Tunica media
Tunica adventitia (outermost)
Aneurysm definition
Dilatation of the aorta ( > 3cm)
Involves all 3 layers of vessel wall
conditions of heart
Dissection
Tear of the tunica intima creates a false lumen
conditions of the heart
Rupture
Full-thickness tear of aorta
Abdominal Aortic Aneurysm
Epidemiology
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
Abdominal Aortic Aneurysm
Risk Factors
Advanced age
Male sex
Tobacco use
Alcohol use
White population
Family history
Atherosclerotic risk factors
Hypertension
Hyperlipidemia
who is at the highest risk of abd aortic aneurysm?
white elderly men with a history of tobacco use and atherosclerotic risk factors
abd aortic aneurysm
Sx
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
abd aortic aneurysm
complications
rupture - very poor prognosis
abd aortic aneurysm
imaging of choice
Abdominal Ultrasound
Diagnostic study of choice for initial screening
Abdominal CT with contrast
Assess diameter
Surgical planning
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
Abdominal ultrasound
Abdominal Aortic Aneurysm
Surgical Repair indications
Diameter > 5.5 cm
Rapid expansion in diameter (> 0.5 cm in 6 months)
Symptomatic – Pain, tenderness
May indicate impending rupture
what diseases make you more prone?
marfans and Ehlers-Danlos syndrome
not testable
abd aortic aneurysm
complications of open repair and endovascular repair
Open repair carries more intraoperative risk, while endovascular repair has higher incidence of post-operative complications
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
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)
Thoracic Aortic Aneurysm
Etiology and Risk Factors
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
Thoracic Aortic Aneurysm
Sx
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
Thoracic Aortic Aneurysm
Imaging
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
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- is the answer
If hemodynamically unstable, dont want CT or MRA
Patient presents with acute chest pain, no ECG changes, and mediastinal widening on cxray…..
TAA
Thoracic Aortic Aneurysm
Surgical repair indications
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
TAA 5-year Risk of Rupture/Death
thoracic aortic aneurysm
What is the risk with surgically repairing a TAA
the more extensive the aneurysm, the greater is the risk of paraplegia with repair.
slide 25
Aortic Rupture
Etiology
Blunt force trauma
High-speed MVC
Rapid deceleration
No use of seatbelt
Sequela of aortic aneurysm
aortic rupture
Triad
Triad:
Severe pain
Hypotension
Pulsatile abdominal mass
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
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
Aortic Rupture
Management
-Endovascular
Specialized surgeons and facilities
Hemodynamically stable patients who have undergone CT imaging
Lower perioperative mortality
-Open
50% survive repair
Aortic Dissection definition
-Spontaneous tear of tunica intima
-Blood dissects into the tunica media
-Repetitive torque during cardiac cycle
-Hypertension
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
Aortic dissection
Debakey and Stanford Classification
dont need this
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
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
Aortic root dissections may present with:
2 sounds, 2 diseases
Diastolic murmur
Aortic regurgitation
Acute heart failure
Cardiac tamponade
when should you consider an aortic dissection?
Consider aortic dissection in hypertensive patients with chest pain and equivocal findings on ECG
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
aortic dissection
Management and Disposition
Labetalol (only one with meds)
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.
PAD
RF
Coronary artery disease
Increased age
Hypertension
Dyslipidemia
Tobacco use
Male sex
Diabetes
Metabolic syndrome
Erectile dysfunction
Family history of cardiovascular disease
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
PAD
Complications
Complication: Chronic limb threatening ischemia -> nonhealing wounds -> gangrene
PAD
Dx
CT gold standard
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
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
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
Chronic Limb Threatening Ischemia
management
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
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
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
Acute Limb Ischemia
Dx
Vascular Sonography
Arterial Doppler Ultrasound
CT Angiography
Delayed intervention
Reserved for viable ischemia
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
treatments for acute limb ischemia
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
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.
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
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
On ECG, there is no ST elevation. Cardiac troponin is negative. What is ruled out? ___________
Non STEMI/STEMI
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
ABI
Ankle brachial index
Normal:1.0-1.4
PAD: less tan or equal to 0.9
Severe disease: less than 0.5
