Chapter 117 - Upper extremity arterial disease - introduction Flashcards
Upper extremity as a percentage of all extremity ischemia
5%
What percentage of diabetics will have abnormal doppler of upper extremity
2-3%
Raynaud’s syndrome prevalence in male, female and north vs south
Female: North 9%; South 4% Male: North 6%; South 3%
Raynaud’s syndrome is further divided
Primary Raynaud’s disease = idiopathic Secondary Raynaud’s phenomenon = identifiable pathology or associated disease; more severe
Most common types of secondary raynaud’s phenomenon
1) Scleroderma 2) Mixed connective tissue disease 3) SLE 4) RA
Causes of arterial vasospasm
1) Ergotism 2) Vinyl chloride 3) Idiopathic Raynauds
Vasoactive Raynauds definition
1) Normal pressure at baseline 2) Hypoperfusion with triggers (Cold, stress, caffeine)
Obstructive Raynaud’s definition
1) Low resting pressure with symptoms 2) Triggers worsen symptoms
Scleroderma definition
1) Generalized disorder of connective tissue microvasculature in small arteries
Scleroderma F:M ratio
3:1 F:M
Prevalence of scleroderma in US
10 in 1 million
Scleroderma on organ level
Severe scarring and vessel occlusion in skin, GI, kidney, lung, heart
Scleroderma genetic
Anti-centromere Anti-topoisomerase (Anti-scl-70)
Percentage of scleroderma that get raynauds phenomenon
80-90%
SLE mechanism
Immune complex deposition
SLE symptoms
1) Fever 2) arthralgia 3) Skin rash 4) Raynaud 5) nephritis
Percentage of SLE with Raynaud’s phenomenon
80%
Mixed connective tissue disease mechanism
Antibody to nuclear antigen Overlap of other connective tissue diseases
Buerger’s also known as
Thromboangiitis obliterans
Buerger’s definition
Segmental thrombotic occlusion of small and medium arteries
Buergers affect this population
young male smokers
Symptoms of Buergers
migratory thrombophlebitis and Raynaud’s syndrome
Diagnostic criteria for Buerger’s
1) Age < 45 2) smoking 3) exclusion of others 4) normal artery proximal to popliteal or brachial 5) digital occlusion
Hand-arm vibration syndrome
1) Raynaud’s syndrome after long term vibrating tool use 2) vasoactive becomes obstructive with time
Fibromuscular dysplasia in upper extremity
Rare May predispose hypothenar hammer syndrome
Hypersensitivity angiitis key points
1) Acute digital ischemia with ulceration without underlying abnormalities 2) Resolves and has a benign course 3) Immune-mediated arterial wall injury
Frostbite in UE ischemia
Vasospastic but can become occlusive if severe
Large vessel arteriopathies
1) Atherosclerotic 2) aneurysmal 3) Takayasu 4) GCA 5) Dialysis access steal 6) iatrogenic
Rate of art lines resulting in pathologies
Radial: 3-10% Brachial: 1-5%
AVF steal when brachial inflow used
5-10%
Acute ischemia and rate of limb loss
Axillary occlusion: 10% limb loss Brachial occlusion distal to deep artery branch: 5% digital gangrene
Pressure difference to indicate significant arm pressure gradient
20 mmHg
Medical treatment in vasoactive spastic
1) conservative avoid trigger 2) calcium channel blocker Nifedipine 3) Losartan 4) Fluoxetine SSUI 5) Prazosin 6) Sidenafil 7) Reserpone 8) Cilostazol 9) Captopril 10) Bosertan (Endothelin receptor blocker) in Scleroderma
Rate of obstructive disease that do not tolerate nifedipine
20-30%
Type of Raynaud with worst prognosis
Obstructive with underlying cause
Chance of ulcer occurrence/recurrence
If no ulcer at initial, unlikely to ever If ulcer at initial, 50% recurrence
Thoracic sympathectomy for UE ischemia
Works in vasospasm but recurrence in 3-6 months No effect in obstructive disease: already maximally dilated
Arterial bypass in UE patency and limb salvage
Patency 83% 3 years Limb salvage 100% 3 years
Causes of hand ischemia
Arterial disease and artery affected
Most common laboratory tests for diagnostic evaluation of UE ischemia
