Arterial Vascular Disease Flashcards
Four main arterial vascular diseases and one minor
- Giant cell Arteritis
- Polymalgia Rheumatica
- Arterial Insufficiency
- Peripheral Arterial Disease
- Aortic Aneurysm/Dissection
Giant Cell Arteritis
- aka
- who does it affect
- what can it cause
- how treat
- temporal arteritis
- primarily people over 50
- blindness
- high-dose steroids
Polymyalgia rheumatica
- who does it affect
- what other dz is it associated with
- how treat
- where see sx on body
- primarily people over 50
- 50% pts with giant cell arteritis have polymyalgia rheumatica
- low dose steroids
- sx below the neck
Pathophysiology of GCA
- exact etiology unknown
- theories: age, ethnicity, genetic disposition (maladaptive response to endothelial injury= inappropriate activation of cell-mediated immunity)
What is the progression of GCA
- vessel wall damage
- intimal hyperplasia
- stenotic occlusion
What blood cell is seen in GCA
eosinophils
- likely but not always high WBC
GCA
- which vessels are affected
- epidemiology
- medium and large arteries, most often the temporal artery
- older than 50, mean age 72
- Women > men
GCA
classic presentation
- HA (temporal region)
- scalp tenderness
- vision: loss of sight in one eye, diplopia
- jaw claudication
what is the highest positive predictive value sx for GCA
jaw claudication
GCA
Non-classic sx
- dry cough (inflammation of aortic arch)
- mononeuritis multiplex, often in shoulder
- idiopathic fever
- > 65
- normal WBC
GCA
- how does blindness occur
occlusive arteritis of posterior ciliary branch of the ophthalmic artery
Timing of funduscopic findings in GCA
might not appear in first 24-48 hours
**don’t rely heavily on funduscopic exam for dx
GCA
- PE head findings
- scalp tenderness
- temporal artery can be normal, nodular, enlarged
- erythema, warmth, swelling
GCA
- PE eye findings
- iritis, fine vitreous opacities
- optic nerve edema
- swollen, pale disc with blurred margins
- pallor
- hemorrhage
- scattered cotton-wool spots
- vessel engorgement/exudates later in dz
GCA
- lab findings
- ESR (90% >50mm/h, typically see >100mm/h)
- CRP
- CBC (mild normochromic anemia, thrombocytosis, WBC normal or elevated)
- Elevated liver function tests, PT
- NL CPK, renal fn, UA
- Elevated interleukin-6 during flairs
ESR vs CRP - which is more sensitive for GCA
CRP is slightly higher
GCA
- imaging
- doppler US to show vascular occlusion, stenosis, edema
What is GCA gold standard for dx
temporal artery biopsy (min length 2 cm d/t incidence of skip lesions)
- will see giant, multinucleated cells
- do contralateral biopsy if suspicion is high but first biopsy was negative
GCA
- Treatment
- 1st line: HIGH dose steroids
- rheumatology and neuro referral
- consider ASA to avoid clots
- PPI for GI protection
- Ca2+, Vit D, bisphosphonate for bone protection
GCA
- major complications (3)
- irreversible blindness
- aortic aneurysms
- polymyalgia rheumatica
Polymyalgia Rheumatica
- describe
- 3 common sx and pertinent negative
- pts won’t be able to do what
- pain and stiffness below the neck
- fever, malaise, weight loss, NO muscular weakness
- pts will have trouble combing hair, putting on coat, getting out of chair
Polymyalgia Rheumatica
- two common lab findings
- anemia
- elevated ESR
- most, not all cases
Polymyalgia Rheumatica
- treatment
- LOW dose steroids
- no improvement in 72 hours f/u
- flair ups can occur
What sx should cause you to put GCA in differential
- > 50
- HA
- Jaw claudication
- fever
- vision changes
what medical hx might find with GCA
DM
Cardiac dz
HTN
Thrombus/thrombi def
clot (platelets and/or fibrin) that forms and is stationary in vessel
embolus/emboli def
piece of thrombus breaks off and travels through bloodstream until it gets stuck
(can be plaque, fat, air, etc.)
Thromboembolism
clot formed in blood vessel and breaks loose, carried by blood stream until gets stuck in another vessel
Arterial insufficiency
- def
- acute, chronic, or both?
- loss of perfusion
- distal to occlusion of major artery due to embolus
- acute AND chronic
Arterial insufficiency
- secondary to what
- emboli
- thrombosis
- trauma
- infection
- inflammation
Arterial insufficiency
- epidemiology
- > 65
- male
- More common in AA
Arterial insufficiency
- leading cause of what in the elderly
limb loss
Arterial insufficiency
- risk factors
- Tobacco use (vasoconstriction)
- endocarditis (clots from affected valves)
- DM
- drug abuse
- cardiac arrhythmia (most likely a fib)
- atherosclerotic dz
- trauma
Arterial insufficiency
- how is genetics related
can be associated with inheritable hyper coagulable states and premature atherosclerotic syndromes
Arterial insufficiency will cause what in the:
- Heart
chest pain
MI
Arterial insufficiency will cause what in the:
- Brain
weakness
CVA
Arterial insufficiency will cause what in the:
- LE
severe claudication
PAD
Arterial insufficiency will cause what in the:
- Mesenteric arteries
- pain after eating
- pain out of proportion to exam
- MAI (mesenteric artery ischemia)
Arterial insufficiency will cause what in the:
- Renal arteries
CVA tenderness
RAI (renal angina index OR renal artery ischemia)
Arterial insufficiency
- four classifications
- Asymptomatic - ex. DM
- Claudication - inadequate blood flow during exercise
- Critical limb ischemia - compromise of blood flow to extremity, limb pain at rest. Often ulcers or gangrene
- Acute limb ischemia - sudden decrease in perfusion that threatens limb viability
What is associated with acute limb ischemia
5 P’s
- pain
- paralysis
- paresthesia
- pulselessness
- pallor
Arterial insufficiency
- Lab tests
- CK/CKMB/Troponin
- PT/INR, PTT
- ABG - look for acidosis
- CBC, CMP
- UA
- Lipids - atherosclerosis
- ESR/CRP
Arterial insufficiency
- Imaging
- CT angiography
- arteriography
- EKG
- ECHO
- Doppler US
- ankle/arm index (AAI) *unequal blood pressure
- ankle/brachial index (ABI) *unequal blood pressure
Arterial insufficiency
- treatment
- Heparin (not coumadin, takes too long)
- Thrombolysis (stent, PTCA, etc.)
- Angioplasty
- Stenting
- Endarterectomy
- peripheral bypass sx
Arterial insufficiency
Major treatment goals
- don’t let it get worse, “thin” blood
2. if occluded, return blood flow around or through
Absolute contraindications for thrombolytic therapy (6)
- recent major bleeding
- recent stroke
- recent major surgery or trauma
- irreversible ischemia of end organ
- Intracranial pathology
- Recent ophthalmologic procedure
Relative contraindications for thrombolytic therapy (5)
- Hx of GI bleed or PUD
- Coagulopathy
- Uncontrolled HTN
- Pregnancy
- Hemorrhagic retinopathy
What sort of onset is Arterial insufficiency
Always sudden
Peripheral arterial disease
- def
- systemic arterial atherosclerosis with partial/total blockage in the arteries. Exclusive of the coronary and cerebral vessels
- resting ankle-brachial index (ABI) <0.90
Describe peripheral arterial disease
- arterial stenosis secondary to atherosclerotic plaque formation
- plaque formation causes inadequate blood flow in distal limbs
- fail to meet metabolic demand during exertion
- acidic products build up and result in claudication
- also causes distal pressures
Most common arteries affected by PAD
- superficial femoral
- deep femoral
- popliteal arteries
80-90%
(tibial and fibular/peroneal arteries 40-50%)
Intermittent claudication
define
- reproducible discomfort within a defined group of muscles that is induced by exercise and relieved by rest
- Sx resolve 2-5 min after pt rests
- leg pain worse when raise leg
- leg pain better with pt lowers leg
Peripher arterial disease
- 5 common findings
- intermittent claudication
- erectile dysfunction
- leg/foot weakness, numbness, tingling
- skin changes - ulcers that won’t heal
- gangrene
Peripheral artery disease
- Fontaine stages of classification
Stage 1: asymptomatic
Stage 2a: intermittent claudication after 200 meters no pain
Stage 2b: intermittent claudication after <200 meters walking
Stage 3: rest pain
Stage 4: Ischemic ulcers/gangrene
Peripheral artery disease
- Diagnostic labs
- check for co-morbidities: serum glucose or HgbA1c
- fasting lipid profile
Peripheral artery disease
- imaging
- duplex ultrasonography and doppler color-flow imaging
- contrast angiography
- CT angiogram
- MR angiogram
what is the best imaging option for Peripheral artery disease
contrast angiography
Peripheral artery disease
- other tests
- Ankle branchial index <0.90
- Toe brachial index <0.6
- segmental limb pressures
- treadmill exercise tests
- segmental volume plethysmography :)
Peripheral artery disease
- treatment goal
- improve quality of life
- improve walking capacity
- decrease morbidity/mortality
Peripheral artery disease
- lifestyle changes
- smoking cessation
- diet
- exercise
- control blood sugar
- control HTN
- decrease lipids
- foot care/appropriate shoes
Peripheral artery disease
- pharm tx
- Antiplatelet
- Clopidogrel
- Ticlopidine
- prostaglandins
- statins
Peripheral artery disease
- intervention tx
- bypass sx
- PTCA w/wo stent placement
Peripheral artery disease graft treatment
4 common complications
- graft occlusion
- infection
- massive bleeding
- limb loss
Peripheral artery disease
- PTA (PTCA)
- less invasive
- lower procedure risk
- lower cost
- preserves sx option if needed later
- improves latency rates with stent vs. angioplasty alone
What is appropriate 1st line tx for aortoiliac obstructive dz
PTA (aka PTCA)
Complications of PTA
- groin hematoma
- pseudoaneurysm
- AV fistula formation
- distal embolization
- thrombotic occlusion
- arterial rupture
Aortic Aneurysm Disease
- two types
- Fusiform: whole circumference or wall of artery
- saccular: not full circumference, asymmetrical bleb or blister on side of aorta
Four types of Aortic Aneurysm Disease
- suprarenal
- pararenal
- juxtarenal
- infrarenal
Aortic Aneurysm Disease
- epidemiology
- > 50
- Males 5: females 1
Aortic Aneurysm Disease
- risk factors
- older age
- male
- family history (1st degree relative)
- smoking
- HTN
- Hyperlipidemia
- PVD
- obsesity
- Marfan
- Ehlers-Danlos
- polycystic kidney dz
Aortic Aneurysm Disease
- etiology
- Atherosclerosis (80%)
- inflammatory dz (5%)
also: - trauma
- connective tissue disorders
- infection
Aortic Aneurysm Disease
- pathophysiology
- vascular inflammatory degenerative dz
- gradual/sporatic expansion of aneurysm
- accumulation of mural thrombus
- localized hypoxia further weakens aneurysm
- tend to expand over time
Aortic Aneurysm Disease
- patient sx
- severe abdominal pain radiating to lower back
- gnawing, burning
- CONTINUOUS
Aortic Aneurysm Disease
- PE findings
- pulsatile supraumbilical mass
- vague abdominal tenderness with palpation
(30-40% detected by PE)
Aortic Aneurysm Disease
- what can the aneurysm encroachment cause?
- vertebral body erosion
- gastic outlet obstruction
- ureteral obstruction
What secondary issue can occur with Aortic Aneurysm Disease
- lower extremity ischemia secondary to embolization of mural thrombus
Aortic Aneurysm Disease
- labs
- CBC
- CMP
- UA
- Amylase (pancreatic enzyme)
- Lipase (pancreatic enzyme)
Aortic Aneurysm Disease
- imaging
- US
- CT angiography
- MRI/MRA
- Abd xray
- aortography
what is best imaging option for sizing/preop planning, what is its downside
CT angiography
- downside is requires contrast, problem with renal failure
Aortic Aneurysm Disease
- pharm tx
- BB
- Statin
- ASA
- smoking cessation, lipid control, diet, exercise
Aortic Aneurysm Disease
- surgical tx
- open repair: good or average surgical candidates
- Endovascular Aortic Repair (EVAR): high risk pts d/t co-morbidities
Compare EVAR and open repair
- similar survival rates
- EVAR has less short-term complications
- EVAR has more long term complications (thrombosis)
Aortic Aneurysm Disease
- elective repair threshold size
- 5.5 cm average pt
- 5 to 5.4 cm younger, low risk pts with long life expectancy
- 4.5 to 5 cm women or high risk of rupture
Aortic Aneurysm Disease
- factors of high risk for rupture
- expansion of > 0.6 cm/year
- smoking, severe COPD, steroids
- family hx
- HTN poorly controlled
- shape is non-fusiform
Aortic Aneurysm Disease
- also have CAD, what should do before aneurysm repair
consider coronary revascularization
Aortic Aneurysm Disease
- screening
- one time US in men 65-75 who have ever smoked
- Men >60 with fam hx
- not for women bc risk so much lower than men
Aortic Aneurysm Disease
- Triad indicative of rupture
- hypotension/shock
- pulsatile mass
- abd pain
Aortic Aneurysm Disease rupture tx
immediate vascular surgery consult
- IV access and resuscitation
- type and cross for multiple units
- bedside US
- endovascular AAA repair
Thoracic aneurysm disease
- parts of aorta
- aortic root
- ascending aorta
- descending aorta
Thoracic aneurysm disease
- hx/PE findings
- most detected incidentally
- Aortic insufficiency - early diastolic murmur, heart failure
- cough, dysphagia, hoarseness
Thoracic aneurysm disease
- imaging
- CXR
- CT Angiogram
- MRA
- Aortography
- TTE/TEE
Thoracic aneurysm disease
- CXR findings
- loss of aortic knob
- widened mediastinum
What is most common imaging for Thoracic aneurysm disease
CT Angiogram
- excellent anatomical detail and sizing
Thoracic aneurysm disease
- sx treatment
- open repair in proximal TAA
- thoracic endovascular aortic repair (TEVAR) in descending aorta
Thoracic aneurysm disease
- non surgical tx
- low-normal BP via BB, ARBS, ACEI
- annual surveillance imaging
Aortic dissection
- def
begins with a tear in aorta intimal, blood enters media, divides it into two layers
Aortic dissection
- pathophysiology
- tear in aortic intima is likely precipitating factor
- aortic media degenerates
- dissection can extend distally and proximally (can involve aortic valve and branch vessels)
- progression - tamponade, ischemia of vessels
- communications might form between true and false lumen
Aortic dissection
- risk factors
LOTS
- HTN
- tobacco
- marfan
- etc etc etc
Aortic dissection
- sx
- acute chest pain “ripping, tearing”
- back or abd pain
- syncopal episodes
- distal ischemia
Aortic dissection
- signs
- cardiac tamponade
- hemothorax (L > R bc heart is on left)
- > 20 mmHg diff in systolic pressure btwn arms
- neurologic deficits
- renal insufficiency
Aortic dissection
- Diagnostic imaging
- CT scan
- Aortography
- MRI
- TEE
Aortic dissection
- auto admission where?
- pain control via what?
- BP and HR tx
- ICU
- morphine
- reduce systolic BP to 100-120 or lowest tolerable
- HR <60
**goal is to reduce aortic shear stress
Aortic dissection
- pharm tx
- IV beta blockers (Esmolol is best bc drip and short half life makes titration easier)
- Cardioselective CCB (Verapamil and diltiazem)
- direct vasodilators
Aortic dissection
- what is definitive tx?
surgical repair
