BV and Lymphatic Disorders Flashcards
A 60 y/o male smoker presents with a 6 month history of impotence along with calf, thigh, and buttocks claudication. Thefemorals are not palpable. Angiogram is shown.This man has a (an):
A. aortic embolism.
B. aortic dissection.
C. aorto-iliac occlusion.
D. thromboangitis obliterans.
E. acute aortic occlusion.
C. aorto-iliac occlusion.
René Leriche of Leriche’s Syndrome
What would be the best Treatment for this Patient (who has aorto-iliac occlusion)?
- Smoking cessation and BP control
- ASA and/or clopidogrel (Prevents MI, CVA , etc).
- Cilostazol (Pletal/phosphodiesterase type 3 inhibitor – inhibits platelet aggregation and dilates vessels) 100 mg BID
- Pentoxifylline (Trental/phosphodiesterase inhibitor with antihemorrheologic activities) 400 mg TID
- Ramipril*
- Statin (rosuvastatin 40 mg daily)
- Stent
- Axillo-femoral bypass; Aorto-fem bypass
- Intermittent calf compression. Angiogenesis with injection of mononuclear cells.
*The imbalance between NO and Ang II activities associated with endothelial dysfunction and risk factors for CAD causes oxidative stress, which
results from excessive production of oxygen-free radicals which counteracts the effects of NO, stimulates expression of adhesion molecules and promotes adhesion of leukocytes to the endothelium. These actions cause an acute inflammatory response, proliferation of smooth muscle cells and production of extracellular matrix, all of which contribute to the pathogenesis of atherosclerosis. (Griendling and Alexander 1997).
Arterial Diseases
A 60 y/o diabetic male presents with cramping pain in both calves with walking 2-4 blocks. The femoral arterial pulses seem somewhat diminished in the groin, the left popliteal and left pedal pulses are diminished. The right pedal pulses are absent. The Ankle/Brachial index is 0.5 on the left and 0.1 on the right. There is no hair on the right toes and the patient has dependent rubor on the right. (see image which shows: Dependent rubor, Rest pain, note: Blanching on elevation would be apparent)
The patient most likely has severe occlusion of the:
A. distal aorta.
B. right iliac.
C. profunda femoris.
D. superficial femoral.
E. tibials.
D. superficial femoral.
If the profundus were involved, the claudication would occur much earlier.
What is this an image of?
Magnetic resonance angiography of the lower extremity demonstrating preocclusive
disease of the superficial femoral artery on the left and occlusion on the right.
The right profunda femoris artery is the source of a rich collateral network in this patient.
- In the above patient who has superficial femoral arterial occlusion, under what conditions would it have been possible to have a more normal ABI on the right (ie .8 or .9) and still have poor circulation?
- What is Osler’s sign or maneuver?
- In the above patient, under what conditions would it have been possible to have a more normal ABI on the right (ie .8 or .9) and still have poor circulation?
_When the vessels are calcified* as in diabetics. This does not allow practical use of ABI and thus one must resort to wave form analysis._
_(Note -*Calcification is a most potent predictor of stent thrombosis)_
- What is Osler’s sign or maneuver?
Pseudohypertension because of calcified vessels.
in the Attached Image you see an example of a using wave form on a patient with ilio-femoral disease on the right.
What would be the treatment for this patient who has superficial femoral artery occlusion?
Treatment of superficial and common femoral and popliteal stenosis
- structured walking program
- Fem-pop bypass*
*absolute indication for surgery – rest pain and non-healing ulceration.
A 55 year old man is seen for progressive bilateral leg and calf pain with ambulation and relief with sitting down in a chair. History is positive for hypertension and the patient is on an ACE inhibitor. Physical examination reveals an S4. Present BP is 130/60. He has a “simian gait” and complains of worse pain with extension of his back and improvement with bending forward. Calves are tender. Pedal pulses are questionably diminished. Which test will most likely be positive?
A. Ankle/brachial index
B. Femoral angiography
C. Lumbar spine xray
D. Lumbar MRI
E. Venous doppler
D. Lumbar MRI
Attached Image shows progressive narrowing of the spinal canal may occur alone or in combination with acute disc herniations. Lumbar spinal stenosis (LSS) remains the leading preoperative diagnosis for adults older than 65 years who undergo spine surgery.
What is lumbar spinal stenosis?
Absence of pain or improvement of symptoms when seated assists in ruling in LSS. Patients with significant lumbar spinal canal narrowing report pain, weakness, and numbness in the legs while walking. Compressed nerve roots become ischemic due to stenosis. This is the hallmark of neurogenic claudication. The pain is relieved when the patient flexes the spine by, for example, leaning on shopping carts or sitting. Flexion increases canal size. The most common nerve affected is the L5, with associated weakness of extensor hallucis longus. Neurogenic claudication pain is exacerbated by standing erect and downhill ambulation and is alleviated with sitting, squatting, and lumbar flexion.
Tibial and pedal artery occlusion
A 45 y/o diabetic presents with burning, dorsal foot pain that is relieved by getting up or dangling the foot. How do you know this is not diabetic neuropathy?
How is the diagnosis made?
What is the treatment?
How do you know this is not diabetic neuropathy?
Relief from dangling.
How is the diagnosis made?
MRA.
What is the treatment?
Vein bypass to distal tibial or pedal arteries.
A 35 y/o male from south Africa presents with sudden onset pain in the right lower extremity. The leg is pale, weak, and numb. The pedal pulses are absent and the foot is cold. The heart rhythm is irregular.
What has happened?
Acute arterial occlusion of a limb
Which is true in regard to the above pt who has arterial occluion of the leg?
A. 50% of cardiac emboli go to the brain.
B. With loss of light touch, surgery can be deferred.
C. Before revascularization, NaCl should be administered.
D. Cause is never due to thrombosis.
E. Pedal pulse are not palpable.
Which is true in regard to the above?
A. 50% of cardiac emboli go to the legs.
B. With loss of light touch, surgery should be done immediately.
C. Before revascularization, NaHCO3 should be administered.
D. Cause is sometimes due to thrombosis.
E. Pedal pulse are not palpable.
What are the 6 Ps
6 Ps of acute arterial occlusion:
Pain
Pallor
Paralysis
Paresthesias
Pulselessness
Poikilothermia*
*poikilo - irregular
A 58 y/o hypertensive, diabetic, female presents with dizziness, diploplia, dysphagia, dysarthria, dysmetria, and ataxia of 50 minutes duration. The patient is having which type of an event?
A. Vertebro-basilar TIA
B. Carotid stroke
C. Brain tumor symptoms
D. Seizure disorder
E. Diabetic neuropathy
A. Vertebro-basilar TIA
Remember: The Ds of VB TIAs
Describe Lateral Medullary Syndrome and Horner’s syndrome.
The Lateral Medullary Syndrome with occlusion of vertebral or PICA = the Ds plus numbness in contralateral arm or leg and ipsilateral face, with Horner’s syndrome
What is the clinical presentation of Lateral Medullary Syndrome with occlusion of vertebral or PICA ?
The Lateral Medullary Syndrome with occlusion of vertebral 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..
Define Carotid Territory TIA
Aphasias, unilateral weakness or numbness, and amaurosis fugax
A 45 y/o hyperlipidemic, diabetic female has had abdominal pain lasting for 2 hours after meals for the past 3 years. She has had a 20 lb weight loss over the past 6 months related to fear of eating. She presents suddenly with periumbilical pain, but no significant clinical abdominal findings except for bloating. The patient has a (an):
A. mesenteric occlusion.
B. ruptured appendix.
C. diabetic neuropathy.
D. pancreatic cancer.
E. inflammatory bowel syndrome.
A. mesenteric occlusion.
What is the treatment of mesenteric occlusion?
•Angioplasty and stent versus aorto-celiac or superior mesenteric bypass
A 65 y/o female with a history of polycythemia and frequent phlebotomies presents with abdominal pain and swelling. Two months ago she had an episode of amaurosis fugax and two weeks ago, she had left sided numbness that lasted for 10 minutes. She has been having abdominal pain after meals for the past 6 months. Hb is 18 gm with WBC of 13,000 and platelets of 350,000. Exam shows abdominal enlargement with dullness to percussion in the flanks. A CT angiogram is performed and shows portal vein thrombosis. What is most unusual in this patient?
A. Amaurosis fugax
B. Abdominal enlargement
C. Polycythemia
D. Portal vein thrombosis
E. Left sided numbness
D. Portal vein thrombosis
What is a red clot?
Basis of a red clot:
Caused by multiple thrombophilic* and /or hypofibrinolytic** factors, mostly inherited. Also due to acquired risk factors (pregnancy, BCPs, high dose steroids, immobilization, surgery, and foreign bodies in the blood stream/catheters.)
*Factor V Leiden, Prothrombin G20210A, ACLA, etc. **4G/5G polymorphism of the plasminogen activator inhibitor-1 gene (PAI-1).
What is a white clot?
Basis of a white clot.
Caused by smoking, hypertension, hyperlipidemia, DM, cholesterol emboli.
What causes arterial and venous clotting?
Heparin induced thrombocytopenia (HIT)
Paroxysmal Nocturnal Hemoglobinuria (PNH)
Myeloproliferative disease (especially JAK 2)
Anti Phospholipid Antibody Syndrome (APLAS)
Anti Cardiolipin Antibody Syndrome (ACLA)
Hyperhomocysteinemia
Thromboangitis obliterans (Buerger’s disease: vasculitis of arteries and veins).
Nephrotic syndrome (antithrombin III, protein S and C deficiency).
Right to left shunt
Popliteal artery aneurysm
What are some key facts to know about Aortic Aneurysms?
- USPFTS: One time screening (for AAA) of 65-75 y/o males who have ever smoked. Insufficient evidence for women.
- Truly significant at 5-6 cm.
- Thrombosis in aortic aneurysms - no anticoagulation
- Do coronary surgery prior to aneurysm repair.
What is the treatment for an aortic aneurysm?
- Labetolol 20 mg over 2 min IV, then 40 -80 mg q 10 min
- Esmolol 0.5 mg/kg IV
- Nitroprusside 50 mg in 1000 D5 at 0.5 mL/min
- Surgical repair or endovascular graft
A tall, thin 35 y/o male presents for a flight physical to renew his license for Delta. During the exam he is found to have a 3/6 diastolic decresendo murmur at the base, with a 2/6 systolic murmur at the apex that lengthens with standing and shortens with handgrip. History is positive for a prior pneumothorax. Which would be an additional finding in this patient?
A. Posterior mid-thoracic machinery-murmur
B. Aortic root dilation
C. Pulseless left arm
D. Hoarseness
E. Paraplegia
B. Aortic root dilation
Which is associated with a dissecting aortic aneurysm?
A. Dissection into the adventia
B. Dull aching chest pain
C. Anterior wall MI
D. Systolic murmur
E. Hypertension
F. Paraplegia
E. Hypertension
F. Paraplegia
•Can also see dissection in pregnancy, bicuspid aortic valve, and coarctation.
What else produces mediastinal widening?
Artifact – patient rotated
Mediastinal Mass – T and B cell lymphoma, teratoma, thyroid, thymus = 4 Ts
Vessels – aortic aneurysm
Anthrax
Describe Peripheral Artery Aneurysms
- An easily palpable popliteal pulse may well be an aneurysm which can present with loss of distal pulse with acute leg or foot pain
- Popliteal aneurysms account for 70% of peripheral arterial aneurysms – risk include thrombosis and embolization.
- In treatment, surgery is indicated for peripheral embolization, > 2cm or a mural thrombus. Often can be conservative if light touch remains in tact.
Venous Diseases
Which of the following predisposes to thrombophlebitis?
A. Tachycardia
B. Exercise
C. NSAIDs
D. Vitamin E
E. Trauma
E. Trauma
What is Virchow’s Triad?
Hypercoagulability (blood)
Stasis (of flow)
Trauma (to the vessel)
This patient had presented with a post-phlebitic syndrome involving the left leg. The clot in the left iliac vein was related to pressure from the:
A. right iliac.
B. left iliac.
C. sacrum.
D. rectum.
E. sigmoid colon
A. right iliac.
May – Thurner syndrome: may account for 30% of all venous events in the US each year.
A 59 y/o male with pancreatic cancer presents with a two week history of a swollen left leg with calf tenderness. Physical exam shows a superficial phlebitis of the left arm.
The cause of these findings is most likely:
A. systemic hypercoagulability.
B. Staphylococcus superinfection.
C. pressure related to the pancreatic mass.
D. related to IV catheters.
E. related to chemotherapy.
A. systemic hypercoagulability.
What is the name of this Systemic Hypercoagulability syndrome?
•Trousseau’s syndrome
Armand Trousseau who diagnosed himself with gastric cancer. Involves mucin (glycans) producing epithelial cancers that activate platelet and leukocyte (P and L) selectins (CD62/glycoproteins or cell adhesion molecules/CAMs) that lead to platelet rich microthrombi (seen most often in adenocarcinoma of the lung).
Thrombogenic cancers: gastric, esophageal, lung, pancreas, renal, ovarian, AML, non-Hodgkins lymphoma*.
Manifestations of cancer as hypercoagulability: Plegmasia cerulean dolens, DIC, TTP, marantic endo, superficial migratory thrombophlebitis,
and arterial thrombosis.
This 72 y/o male with a traumatic ulcer on his ankle most likely has:
A. venous insufficiency.
B. arterial insufficiency.
C. pyoderma gangrenosum.
D. cellulitis.
E. sickle cell anemia.
A. venous insufficiency.
- Characterize this ulcer:
- What is characteristic of a neuropathic ulcer?
- Venous Ulcer
- Neuropathic ulcer*
History of numbness
Common in DM
Pressure site
Variable depth
Surrounding callus
Cap refilling normal
ABI = normal
*Diabetic foot infections: more likely with positive probe to bone test, ulcer duration > 30 days, trauma , PVD, peripheral neuropathy, and RI.
What are causes of Venous Ulcers?
History of trauma, pregnancy, and varicose veins
Medial malleolus
Superficial, irregular margins
Ruddy, beefy, fibrinous, granulation
Edema
Dermatitis
Lipodermatosclerosis –indurated
Hyperpigmentation - hemosiderin
Moderate to heavy exudate
Cap refilling - < 3 sec (Normal)
ABI = 0.9 or greater
•
What are causes of Arterial ulcers?
History of smoking, rest pain claudication
Site of pressure
Deep, “punched out” with sharp borders
Bed pale grey or yellow
Dry necrotic base with eschar
Lateral
Pale, hair loss, cold feet, atrophic skin, no pulses
Cap filling >4-5 sec.
Elevation pallor < 15 sec.
ABI = 0.5 or less
Causes of Chronic leg ulcers
PAD
Venous insufficiency
DM
Autoimmune diseases (Felty’s)
SS anemia
Vasculitis
Panniculitis
Infection (fungal)
Hypertension (Martorell’s)
What is the Treatment for Septic Superficial Thrombophlebitis?
- Vancomycin 15 mg/kg IV q 12 hrs
- Ceftriaxone 1 gm IV q 24 hrs
What is Phlegmasia Cerulean Dolens
Phlegmasia Cerulean Dolens*
Literally inflammatory (edematous), blue, and painful, ie. painful, sky blue and inflamed! Due to primary venous insufficiency with secondary arterial insufficiency (not so in AF where emboli cause primary arterial occlusion and pallor occurs).
Most common cause is cancer, though may be obesity, old age, immobilization, or other procoagulant conditions (Factor V Leiden, etc) .
*may get massive fluid loss with decreased BP, or even vasodilatory shock from inflammatory mediators. Phlegmasia alba dolens has to do with colateral veins allowing some drainage so that tissue ischemia does not occur.
Describe the Treatment of Phlegmasia Cerulean Dolens*
Treatment:
- Fluid
- Anticoagulation
- Evaluate for cancer
A 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:
A. mets to the brain.
B. CVA.
C. vena cava obstruction.
D. pulmonary embolus.
E. pneumonia.
C. vena cava obstruction.
Which type of lung cancer would this be when a Pt presents with SVC Obstruction?
Non small cell lung cancer is the most common cause of the vena cava syndrome* followed by small cell and then lymphoma . Pancoasts syndrome is more often due to NSCLC as well, especially squamous and adenocarcinoma.
What else causes SVC obstruction?
Causes of SVC obstruction:
Cancer
Chronic fibrotic mediastinitis (reaction to Histoplasmosis antigen)
DVT from arm veins
Aortic arch aneurysm
Constrictive pericarditis
A 35 y/o black female presents with malaise, anorexia, sweating, chills, fever and throbbing pain in the left arm. There is warmth at the left antecubital fossa and a faint red streak is discovered over the dorsal left hand. The left axillary nodes are swollen. She denies any bites.
The most appropriate question would be as to whether or not she has a:
A. cat.
B. horse.
C. dog.
D. parrot.
E. Ferret.
A. cat.
List the other diseases borne by the nasty ass cats. (aka Santan’s Minions)
Cat-Borne Diseases
Saliva:
Bartonella henselae
Pasteurella multocida
Rabies
Capnocytophagia
Tularemia
Fecal:
Toxoplasma gondii
Cryptosporidium
Salmonella
Campylobacter
Ancyclostoma braziliense (Hookworm)
Toxacara cati (Round worm)
Aerosol:
Coxiella burnetti
Tick or flea bites:
Lyme disease
Ehrlichiosis
Babesiosis
Yersinia pestis
Urine:
Leptospirosis
Direct contact:
Sporothrix schenckii
Microsporum canis (Ringworm)
The patients as pictured have which entity?
A. Cellulitis
B. Lymphangitis
C. Phlebitis
D. Lymphedema
E. Lymphadenitis
D. Lymphedema
What causes lymphedema and what are its characteristics?
- Lymphedema = pitting edema without ulcers, varicose veins or stasis pigmentation
- Milroy’s disease 1892 – (described in a missionary from India) – congenital lymphedema with break in the VEGFR 3 gene (the gene controls lymphogenesis)
- Stewart-Treves syndrome – actually a hemangiosarcoma rather than a lymphangiosarcoma due to local immunodeficiency (possibly radiation contributes)
These patients with adiposa dolorosa have which entity?
A. Cellulitis
B. Lymphangitis
C. Phlebitis
D. Lymphedema
E. Lipedema
E. Lipedema
Different than Lymphadema bc the feet are not involved
