Blood Vessels and Lymphatic Disorders Flashcards
hx of impotence, calf, thigh and buttocks claudication. femorals not palpable?
aorto-iliac occlusion
tx for aorto-iliac occlusion?
- smoking cessation and BP control
- ASA and/or clopidogrel (prevents MI, CVA)
- Cilostazol (phosphodiesterase inhibitor w/ antihemorrheologic activities)
- Ramipril
- statin (i.e. rosuvastatin)
- stent; axillo-femoral bypass
- intermittent calf compression
P2Y12
signaling molecule found on platelets that modulates thrombin generation –? affecting ADP feedback loop
The drugs clopidogrel (PLAVIX), prasugrel (Efient, Effient) and ticagrelor (BRILINTA) bind to this receptor and are marketed as antiplatelet agents.[3]
Cilostazol, Pentoxifylline
Cilostazol and Pentoxyfyline stop activation of calcium and stop platelet activation
- pain in both calves while walking 2-4 blocks
- femoral arterial pulses dimished in groin, left popliteal and left pedal pulses
- right pedal pulses are absent
- ankle/brachial is 0.5 on left, 0.1 on right
- no hair on right toes, rubor on right side
occlusion of superficial femoral
- if profunda femoris was involved, claudication would occur much earlier (this provides a collateral to the superficial femoral)
Osler’s sign/maneuver
The Osler’s sign of pseudohypertension is an artificially and falsely elevated blood pressure reading obtained through sphygmomanometry due to arteriosclerotic, calcified blood vessels which do not physiologically compress with pressure.
Because the stiffened arterial walls of arteriosclerosis do not compress with pressure normally, the blood pressure reading is theoretically higher than the true intra-arterial measurement.
note: when the vessels are calcified as in diabetics, you can’t use ABI and must instead use wave form of analysis
tx for patient with superficial or common femoral popliteal stenosis?
femoral-popliteal bypass
- progressive bilateral leg and calf pain with abulation
- relief when siting in chair
- concurrent HTN, and S4 present
- BP 130/60
- “simian gait”
- pain worsens with extension of back, calves are tender, pedal pulses diminished
“simian gait” = waddling
- should get a lumbar MRI b/c this patient has spinal stenosis, which can look like PVD
dimished pedal pulses due to intermittent neurogenic claudication characterized by lower limb numbness, weakness, diffuse or radicular leg pain associated with paresthesis (bilaterally),[7] weakness heaviness in buttocks radiating into lower extremities with walking or prolonged standing.[5] Symptoms occur with extension of spine and are relieved with spine flexion. Minimal to zero symptoms when seated or supine.[5]
S4
atrial contraction into nomcompliant vecntricle - seen in HTN and diabetes -> stiff ventricles
- diabetic pt with burning, dorsal foot pain that is relieved by dangling the foot
- tibial/pedal artery occlusion
- you know its not diabetic neuropathy b/c its relieved by dangling feet
- ddx is made via MRA
- tx: vein bypass to distal tibial or pedal arteries
NOTE: dorsalis pedis is not always palpable, however posterior tibialis should always be felt, if not it indicates PVD
PVD
- aka PAD = obstruction of large arteries not within the coronary, aortic arch vasculature, or brain.
- PVD can result from atherosclerosis, inflammatory processes leading to stenosis, an embolism, or thrombus formation.
- can cause acute or chronic ischemia
Sx:
- Claudication—pain, weakness, numbness, or cramping in muscles due to decreased blood flow
- Sores, wounds, or ulcers that heal slowly or not at all
- Noticeable change in color (blueness or paleness) or temperature (coolness) when compared to the other limb (termed unilateral dependent rubor; when both limbs are affected this is termed bilateral dependent rubor)
- Diminished hair and nail growth on affected limb and digits
claudication
impairment in walking, or pain, discomfort or tiredness in the legs that occurs during walking and is relieved by rest.
causes of PAD
smoking, DM, dyslipidemia, HTN, obesity
DDx of PAD?
- take ABI
- CT scan
- MRA: magnetic resonance angiography
35 y/o male presenting with sudden onset pain in right LE - leg is pale, weak, numb - pedal pulses are absent and foot is cold. heart rythm is irregular, what is the problem?
= Acute Arterial Occlusion of Limb
- clot has been thrown from the heart into the femoral popliteal –> resulting in acute arterial occlusion of the limb
- see pedal pulse that is not palpable
where do 50% of cardiac emobli go to/
the legs
what does loss of light touch indicate?
need to go to surgery, as pt. is having neurologic changes
what do you administer before revascularization of the leg?
administer bicarb, hypoxia and lactic acid will be present in occluded limb - want to try to reverse the localized lactate
6 P’s of Acute Arterial Occlusion? **
Pain, Pallor, Paralysis, Paresthesias, Pulselessness, Poikilothermia (irregular temperature)
Vertebro-Basilar TIA
the D’s of VB TIA’s:
- dizziness, diplopia, dysphagia, dysarthria, dysmetria, ataxia
NOTE: need to tx with aspirin and get an MRA
what are two arterial systems feeding the brain?
carotid in front, vertebral basilar system in back
lateral medullary syndrome
occlusion of vertebral artery or PICA
= ringing in the right ear, dizziness and
right facial pain. There is nystagmus on right lateral gaze.
There is right perceptive deafness. Intention tremor is present
on the right with falling to the right with Romberg position.
There is loss of pain and temperature over the right face
and opposite trunk and extremities with ptosis of the right eye
and constriction of the right pupil..
Carotid TIA sx?
aphasia, unilateral weakness, numbness, amaurosis fugax (shade comes down over eye on one side)
- also see receptive aphasia
hx: hyperlipidemia, DM, abdominal pain lasting 2 hours after meals for past 3 years. 20 lb w/l, fear of eating. presenting with periumbilical pain, no clinical findings except for bloating
mesenteric occlusion
- abdominal pain after meals = abdominal angina (can’t get blood to digest food)
- hx is compatible with abdominal angina: find NOTHING on PE
- can become very serious with bowel infarction
tx of mesenteric occlusion?
angioplasty and stent, better than aorto-ciliac/ superior mesenteric bypass
red clot
hypercoagulability and stasis (could be due to factor V deficiency, protein S/C deficiency or anything causing stasis)
- caused by multiple thrombophilic (Factor V Leiden, Prothrombin G20210A) or hyofibrinolytic factors
- also due to acquired risk factors of pregnancy, BCPs, high dose steroids, immobilization, surgery, blood stream catheters
white clot
due to platelet aggreation, caused by atherosclerotic risk factors
- caused by smoking, HTN, hyperlipidemia, DM, cholesterol emboli
what diseases cause arterial/venous clotting?
- Heparin Induced Thrombocytopenia (HIT)
- Myeloproliferative disease (espec. JAK2)
- thromboangitis obliterans (Buerger’s disease: vasculitis of arteries and veins)
- nephrotic syndrome (antithrombin III, protein S/C deficiency)
Others:
- Paroxysmal Nocturnal Hemoglobinuria (PNH)
- Anti Phospholipid Antibody Syndrome (APLAS)
- Anti Cardiolipin Antibody Syndrome (ACLA)
- Hyperhomocysteinemia
- Right to left shunt
- Popliteal artery aneurysm
Aortic Aneurysm
- widening of aorta
- significant if 5-6 cm or larger
- do not use anticoagulants as may put at greater risk for rupturing
- do conary surgery prior to aneurism repair (if someone has AAA they have CAD as well, before repair of AAA need to repair CAD)
- males that have smoked should always be screend for AAA at 65-75 y/o
tx for aortic aneurysm?
- Labetolol 20 mg over IV, then orally in ten minutes
- esmolol: 0.5 mg IV (drops blood pressure)
- nitroprusside
- surgical repair or endovascular graft
what are common findings in marfan syndrome?
- aortic insufficiency (diastolic decresendo murmur at base)
- not standard mitral regurgitation, MVP (systolic murmur at apex that lengthens with standing and shortens with handgrip)
- ** aortic root dilation
what does handgrip do?
increases peripheral pressure which results in increased afterload on heart as heart is trying to empty through the aortic valve
what does standing do?
- decreases work load on heart, decreased afterload –> would cause shortening of mitral insufficiency murmur
what is associated with dissecting aortic aneurysm?
- dissection into media
- sharp tearing chest pain
- inferior wall MI: dissect down into valve, b/c right coronary artery comes off near aortic valve
- diastolic murmur present, due to aortic insufficiency
- Often due to HTN
- Paraplegia seen in 4% of patients: where the vessels of spinal cord come off of descending aorta, and results in lack of blood flow to spinal cord in descending aortic aneurysm
when do you often see dissection of AA?
pregnancy, bicuspid aortic valve, coarctation of aorta
sx of dissecting ascending vs descending TAA?
- Anterior chest pain is associated with dissections involving the ascending aorta,
- interscapular (back) pain is associated with descending aortic dissections.
Note: If the pain is pleuritic in nature, it may suggest acute pericarditis caused by hemorrhage into the pericardial sac.
sx of dissecting TAA?
- Sudden searing chest pain with radiation to theback, abdomen, or neck in a hypertensive
patient.
`- Widened mediastinum on chest radiograph. - Pulse discrepancy in the extremities.
- Acute aortic regurgitation may develop.
what can produce mediastinal widening?
- artifact, patient is rotated
- mediastinal mass: T/B cell lymphoma, teratoma, thyroid, thymus (4 Ts)
- aortic aneurysm
- anthrax
Peripheral Artery Aneurysm
- easily palpable popliteal pulse can present with loss of distal pulse/acute leg or foot pain
- popliteal aneurysms account for over 70% of peripheral arterial aneurysms, with risks of thrombosis and embolization
- surgery is indicated if peripheral aneurysm is >2cm
- can be conservative if light touch remains in tact
what predisposes to thrombophelbitis?
vircHow’S Triad:
- Hypercoagulability
- Stasis
- Trauma
thrombophlebitis?
Thrombophlebitis is phlebitis (vein inflammation) related to a thrombus (blood clot).
- blood clots blocking vv. often occurs in legs
Troussea’s Syndrome
a medical sign found in certain cancers that is associated with venous thrombosis and hypercoagulability. It is characterized by successive crops of tender nodules in affected veins.[2] It is also referred to as Trousseau syndrome[3] and is distinct from the Trousseau sign of latent tetany.
The pathological phenomenon of clots forming, resolving and then appearing again elsewhere in the body has also been named thrombophlebitis migrans or migratory thrombophlebitis, as opposed to plain thrombophlebitis in one location.
reason for hypercoagulability with cancer?
epithelial cancers activate platelet and leukocyte (P and L selectins and glycoproteins/cell adhesion molecules) that lead to platelet rich microthrombi
- seen most often in adenocarcinoma of lung
what are thrombogenic cancers?
adenocarcinoma of lung, gastric, esophageal, pancreas, renal, ovarian, AML, non-Hodgkins lymphoma
medial ankle ulcers?
usually due to venous insufficiency
lateral ankle ulcers?
usually due to arterial insufficiency
venous ulcers?
- hx of trauma, pregnancy, varicose vv
- medial maleolus
- superficial, irregular margins
- ruddy, beefy, granulation
- edema
- indurated hyperpigementation
- heavy exudate
- ABI of 0.9 or greater
arterial ulcers?
hx of smoking, resting pain claudication
- occur at sites of pressure
- deep punched out, with sharp borders
- bed is pale grey/yelow
- dry necrotic base
- lateral malleolous
- pale, hair loss, cold feet, no pulses
- ABI is 0.5 or less
neuropathic ulcer
- hx of numbness
- common in DM
- occur in pressure sites
- surrounded by a callus
- ABI is normal
what are some reasons for chronic leg ulcers?
PAD, venous insufficiency, DM, AI’s, SS anemia, erythema induratum, vasculitis, fungal infection
how to tx septic superficial thrombophlebitis?
vancomycin or ceftriaxone
Phlegmasia Cerulean Dolens
= edematous (inflamm.), blue, painful
- due to primary venous insufficiency with secondary arterial insufficiency (vv. are closed off and legs can’t drain, so it swells up so much that it blocks arteries - in jeopardy of losing legs)
- most common cause is cancer; obesity, old age and immobilization are other factors
Note: if it was primarily arterial blockage, then leg would start out looking white
tx: fluid, anticoagulation, evaluate for cancer
hx: 64 y/o male with lung cancer presents with dizziness, blurred vision and headache. Physical exam shows flushed facies and dilated neck veins. This patient has developed
superior venal cava syndrome
- non- small cell carcinoma = most common cause of SVC
- small cell and lymphoma are next most common
Pancoast syndrome
produced by pancoast tumor - a tumor of the pulmonary apex.
most often due to NSCLC (squamous and adenocarcinomas most often)
Pancoast syndrome, is pain in the shoulder and along the ulnar nerve distribution of the arm and hand.
bronchiogenic carcinoma
during day the vena cava drains out with gravity but during night it is obstructed and pt. wakes up with facial edema
cat scratch fever
“bartonella henselae” due to saliva - resulting in lymphadenitis
lymphedema
pitting edema without ulcers, varicose vv. or stasis pigementation
Milroy’s disease
congenital lymphedema with break in VEGFR3 gene (which controls lymphogenesis)
Stewart-Treves syndrome
– actually a hemangiosarcoma rather than a lymphangiosarcoma due to local immunodeficiency (possibly radiation contributes - thus can be seen in elderly women who have had breast surgery –> lymphangiosarcoma)
