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Cardio Exam 5 > Arterial Disease > Flashcards

Arterial Disease Flashcards

1
Q

An ____ refers to a weakening of an artery wall that creates a bulge, or distention, of the arter

A

aneurysm

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2
Q

Normal abdominal aorta diameter is
approx _____

A

2-2.5 cm
● A diameter > 3 cm = aneurysm

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3
Q

An aneurysm Rarely ruptures until > ___ cm

A

5

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4
Q

Atherosclerosis is the main predisposing
factor for

A

Aortic Aneurysm

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5
Q

Most accepted theory of pathogenesis of Atherosclerosis and Aneurysms

A

● Environmental and genetic risk factors lead to
aortic atherosclerosis.
● Resultant remodeling, intimal thrombosis, and
release of inflammatory cytokines occurs in the
aorta.
● This stimulates arterial wall degradation,
weakening and promoting AAA development.
The Internet Pathology Laboratory
for Medical Education

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6
Q

90% of AAA are located ____

A

below the renal
arteries

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7
Q

Aortic Aneurysm S/S

A

Most AAA are asymptomatic
○ 80% of aneurysms > 5 cm are
palpable on examination
○ Most are discovered as incidental
findings during CT imaging during
the evaluation of other unrelated
symptoms
If symptomatic:
○ Pain
○ Rupture
i. Severe pain
ii. Hypotension
iii. Palpable abdominal mass
Lethal
Triad
Aortic Aneurysm

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8
Q

Lethal triad of a ruptured AAA

A

i. Severe pain
ii. Hypotension
iii. Palpable abdominal mass

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9
Q

Imaging - AAA

A

Abdominal Ultrasound =
Diagnostic study of choice for
screening and follow up

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10
Q

When is CT scan indicated for AAA?

A

Utilized when aneurysm diameter
nears 5.5 cm diameter threshold
for treatment
Used for preoperative planning

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11
Q

Frequency of US Imaging (after
AAA confirmed)

A

● Q 2 yrs = <4 cm
● Q 6 months = 4-5.5 cm

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12
Q

AAA treatment

A
  1. Elective Surgical Repair
    a. If > 5.5 cm diameter
    b. Rapid expansion: >0.5 cm in 6
    months
    c. Endovascular approach (EVAR)
    is an option
  2. Emergent Surgery (open)
    a. For ruptured aneurysms
    b. 50% survival rate
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13
Q

Leading cause of death for those with AAA

A

MI

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14
Q

AAA is a _____ risk factor

A

cardiac

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15
Q

When to refer a AAA:

A

● > 4 cm aneurysm (lower threshold for
women– due to being 3X more likely to
rupture than men)
● Associated pain with aneurysm regardless of
size

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16
Q

Abdominal Aortic Aneurysm
Screening (USPSTF) guidelines

A

● One time US screening for:
○ Men aged 65-75 yrs who are
past or current smokers
● Screening recs are insufficient
in women:
○ Women aged 65-75 who
have ever smoked and/or have a family h/o AAA
should be considered
● If not enlarged, no repeat screening necessary

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17
Q

Most thoracic aortic aneurysms are due to _____

A

atherosclerosis

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18
Q

Greater than 50% of normal diameter is considered aneurysmal for

A

Thoracic aneurysms

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19
Q

Signs and Symptoms of Aortic aneurysms

A

Most are asymptomatic
When symptomatic, depends on
size, location & rate-of-growth:
1. Substernal chest or back pain
2. Neck pain
3. Pressure on the trachea, esophagus,
or superior vena cava can result in:
a. Dyspnea
b. Stridor
c. Cough
d. Dysphagia
e. Edema in the neck and arms
f. Distended neck veins
g. Hoarseness

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20
Q

_____ causes
hoarseness in a thoracic aneurysm

A

Stretching of the left recurrent laryngeal
nerve

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21
Q

Imaging of an aortic aneurysm

A

Chest X-ray - May see the calcified outline
of the widened aorta
CT with contrast - Imaging of choice

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22
Q

lesions that can
mimic an aortic aneurysm:

A

○ Substernal goiter
○ Neoplasms

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23
Q

Aortic Aneurysm screening guidelines

A

● Urgent and definitive imaging needed to identify or exclude in patients at high
risk
● Aortic imaging recommended for first-
degree relatives of parents with TAA or dissection to identify asymptomatic
disease.

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24
Q

Treatment of TAA

A

Indication for repair depends
on location, rate of growth, and
the condition of patient.
Elective repair
● If >6 cm diameter
● Descending aorta: Thoracic
Endovascular Aneurysm
Repair (TEVAR) preferred,
● Ascending aorta and arch
aneurysms: Open surgery

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25
Ruptured TAA
high mortality rate There is also a higher degree of mortality with thoracic/ascending aortic aneurysm repair
26
Aortic Dissection
Aortic Dissection occurs when a spontaneous intimal tear develops and blood dissects into the media of the aorta ● True emergency - place high on the differential of chest pain
27
Pathophysiology of Aortic Dissection
● Usually the result of repetitive torque during the cardiac cycle. ● Most common site is the ascending aorta- 60% of all aortic dissections
28
Two types of aortic dissection:
Type A: Proximal or ascending Aorta Type B: Distal or descending
29
Risk Factors for Aortic Dissection
● HTN ● Tissue or collagen abnormalities ● Pregnancy ● Congenital heart defects
30
Signs & Symptoms of Aortic dissection:
● Severe, persistent chest pain ○ Radiation to the back ○ Radiation to the neck ● Syncope ● Diminished peripheral pulses ● Unequal blood pressures (systolic difference of 20 points) ● Diastolic murmur (from acute aortic regurgitation) ● Paraplegia from spinal cord ischemia
31
Aortic Dissection diagnosis
● Imaging of choice - CT with contrast (chest and abdomen), or CT angio ● Aortic dissection is most commonly misdiagnosed as an MI
32
Aortic Dissection treatment
● Aggressive blood pressure management upon suspicion- before imaging if possible ○ B-blockers - IV ○ Consider Nitroprusside with beta-blocker ○ Opiates for pain ○ Surgical Intervention
33
First line medication for aortic dissection
Labetalol is a first line option. It ↓ pulse pressure and achieves rapid blood pressure control
34
When is surgical intervention needed for Aortic Dissection
Type A - Immediate/urgent surgery. Otherwise the mortality rate increases approximately 1% per hour Type B - Only need surgical repair if evidence of rupture or major branch occlusion. May monitor as long as blood pressure is managed. - Requires yearly CT scans - Consider elective repair if > 6cm
35
Peripheral artery disease AKA Peripheral Vascular Disease
PAD is evidence of a systemic atherosclerotic process ● Most commonly found in the lower extremities ○ Can occur in any peripheral artery such as the UE or carotid
36
Location of these atherosclerotic plaques in PAD are commonly seen in three arterial anatomic locations:
○ Aortoiliac segment ○ Femoral-popliteal segment, ○ Infra-popliteal or tibial segment
37
PAD S/S
● 20-50% are asymptomatic ● Intermittent Claudication - severe, cramping pain, usually occurs in the calf ● Aortoiliac disease ● All vessel sxs ○ Limb fatigue ○ Leg weakness ○ Pulses are absent/weak. Low ABI. ○ Aortic, iliac or femoral bruits ○ Atrophic changes of the leg and foot ■ Loss of hair/Shiny skin ■ Atrophied muscles ■ Ischemic ulcers/changes
38
Aortoiliac occlusion triad:
1. Bilateral lower limb claudication 2. Impotence 3. Decreased distal pulses/lower extremity muscular atrophy
39
Imaging of PAD
● Best INITIAL test = Doppler US ● GOLD standard = Angiography (CT/MR)
40
Risk factor reduction for PAD
● Smoking cessation ● Lipid & HTN management ● Weight loss
41
Treatment of PAD
Risk factor reduction Endovascular Approach ● Angioplasty and stenting Surgical Approach ● Bypass graft (prosthetic/vein) ● Only if failed conservative tx and endovascular is not an option Amputation-last resort. Life or limb
42
Prognosis of PAD
● Life expectancy is limited by concomitant cardiac disease with a mortality rate of 25–40% at 5 years. ○ Have a high suspicion for CAD in any patient found to have PAD or carotid stenosis
43
Acute Peripheral Arterial Occlusion
Acute occlusion of a limb usually due to an embolism or thrombosis of a diseased thrombotic segment
44
Emboli segments large enough to occlude proximal arteries are usually from _____
the heart
45
______ is the most common cause of thrombus formation
Atrial Fibrillation
46
Acute Peripheral Arterial Occlusion classic history
● Hx of intermittent claudication ● May have minimal increase in sxs due to collateral circulation
47
S/S of Acute Peripheral Arterial Occlusion
● Pain (sudden onset, severe) ● Pulselessness ● Neurologic dysfunction ○ Paresthesias ○ Paralysis ● Signs of Ischemia ○ Pallor ○ Poikilothermia
48
Imaging for Acute Peripheral Arterial Occlusion
1. Doppler US - Best initial test 2. MRA/CTA - Most accurate study but not always possible Delay obtaining MRA or CTA in this case. The delay of revascularization could jeopardize the viability of the extremity
49
Treatment of Acute Peripheral Arterial Occlusion
● Immediate revascularization within 3 hours ● Unfractionated heparin as soon as diagnosis is made ● Endovascular directed TPA via catheter ● Surgical intervention ○ Thrombectomy/Embolectomy ○ Bypass
50
Primary raynauds disease vs. secondary raynauds phenomenon
Primary - the occurrence of the vasospasms alone, with no association with another illness Secondary - vasospasms associated with a variety of rheumatologic and non- rheumatologic diseases, environmental exposures, and/or medications
51
Presentation of Raynauds
● Initial Phase - vasoconstriction ○ Digital color changes (white to blue to red) ○ Chronic cases can worsen to gangrene ● Recovery phase - vasodilation ○ Intense hyperemia ■ Rubor
52
Treatment of Raynauds
● Gloves or mittens in cold weather ● Keep body warm ● Protect hands from injury- slow wound healing ● Calcium channel blockers (Nifedipine) ○ More effective in primary type ● Sildenafil- vasodilates ● Sympathectomy if affecting well being or if trophic changes of the skin.
53
Raynaud presentation is almost always ______
symmetrical
54
Thromboangiitis Obliterans (Buerger Disease)
● Distal extremities involved with severe ischemia, progressing to tissue loss. ● Inflammatory, and thrombotic process of the distal- primarily arteries (sometimes veins) of the extremities ● Most commonly affected arteries are: ○ Plantar & digital vessels of the foot and lower leg. ● Advanced disease involves: ○ Fingers ○ Hands
55
_____ is Rarely seen in non smokers
Thromboangiitis Obliterans (Buerger Disease)
56
Signs & Symptoms of Buerger disease
● Rarely seen in non smokers. ● Usually patient is younger than 40 years of age ● Lesions are usually on the toes ● May present with claudication of feet, legs, hands
57
This disease is resistant to NSAIDs, steroids, and blood thinners despite its inflammatory pathology
Buerger disease
58
Arteriovenous (AV) Malformations
Congenital vascular malformations that consist of abnormal arteriovenous communications without intervening capillaries (normal anatomy) ● Can be located anywhere in the body- most common in the brain
59
Signs & Symptoms of Arteriovenous (AV) Malformations
● Symptoms vary depending on where AVM is located ● Progressive loss of neurological function ● Headaches ● Nausea and vomiting ● Seizures ● Loss of consciousness ● Dizziness ● Back pain ● Hallucinations ● Learning disabilities ● Behavior problems
60
Causes & Risk Factors of AV malformations
● Rare - prevalence 1 in 100,000 ● Most occur without family history ● 50% diagnosed after 1st bleed
61
Imaging of AV malformations
● CTA ○ Identifies large AVMs ○ Indicates whether bleed in subarachnoid or intracranial ○ Used to plan treatment ● Arteriography ○ Used when intracranial hemorrhage is confirmed but source is not evident on CT scan ○ May show AVM ● MRI ○ Essential to diagnose AVMs Surgery: Justified for pt with AVM that have bled Endovascular embolization: Blocks flow of blood to AVM Stereotactic radiosurgery: Non-surgical radiation therapy. It can deliver precisely-targeted radiation.
62
Ankle Brachial Index (ABI)
● Non-invasive way to monitor risk of peripheral artery disease. ● Compares blood pressure measured at the ankle with a blood pressure reading measured at the arm
63
Who should have an ABI done?
● Anyone with claudication or rest pain ● Screening ○ Any patient who is > 60 yo ○ Any patient who is > 50 yo and a smoker or diabetic

Cardio Exam 5 (3 decks)

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