Complete Vascular Lecture Flashcards
Peripheral vascular disease involves all blood vessels except in the head or the chest. They involve
1.
2.
3.
Atherosclerotic (chronic)
Thrombotic (acute)
Aneurysmal
Atherosclerotic-chronic has approx 30% prevalence in age __________ (without risk factors) or age ___________(with risk factors)
The risk factors are
1.
2.
3.
4.
5.
6.
70+
50+
high cholesterol, smoking, HTN, obesity, DM, physical inactivity
Atherosclerotic chronic is the reduction of blood flow due to ____________. Typically its a build up of _____________________ in the arterial wall. Theres functional (________________) vs critical ischemia (________________)
stenosis.
fats, cholesterol, calcium in the arterial wall.
normal blood flow at rest
reduction of blood flow at rest
Reduction of cardiovascular risk factors for atherosclerotic chronic
smoking cessation, BP control/lipid control/weight control
Excercise rehab for atherosclerotic chronic
creating collateral flow-Buerger excercise
Foot-care (in PVD and with DM) for atherosclerotic chronic
protection of skin (not walking around barefoot) trimming nails to prevent ingrown nails/wounds
Pharmacotherapy for atherosclerotic chronic
antiplatelet therapy (aspirin, plavix)
What are the symptoms associated with atherosclerotic chronic?
- Pain/cramping(claudication-pain with activity)
Constant pain = progression of disease and decreased oxygen to tissues.
-buerger’s exercises: push beyond pain > rest> angiogenesis due to lack of oxygen > tumor cells produce VEGF> formation of new vessels from existing vessels
- Hair loss due to lack of nutrient rick blood flow and trophic changes that destroy hair follicles
- Shiny appearance of skin- bc lack of blood flow
What is the diagnosis for atherosclerotic chronic?
- examine if they have pulses
- PVR/ABI (pulse volume recording/ankle brachial index) duplex ultrasound
- CT-angio
- Arteriogram +/- stent if disease is found
What is the treatment for atherosclerotic chronic?
conservative:
1. single antiplatelet tx even with a stent
2. exercise
3. statins
4. pletal (cilostazol) 100 mg PO BID (antipletelt/vasocilator)
endovascular- angioplasty,atherectomy, stenting
surgical bypass
What are the levels of amputation?
1.
2.
3.
4.
5.
6.
- hip disarticulation
- above the knee
- below the knee(at least 8cm of the tibia is required below the knee joint for optimal fitting of a prosthesis) Long transtibial amp occurs when more than 50% of the tibial length is preserved.
- symes/chopart/lisfranc
- transmetatarsal
- hallux/digit
Reasons to amputate
1.
2.
3.
Lidocaine injections with epinephrine are great for __________ but NEVER use in _______________(fingers, toes, nose, lobes, hose)
- severe pain
- sepsis/gangrene (wet vs dry gangrene)
- infection vs no infection
hemostasis
distal phalanges
Define wet gangrene
no demarcation line + odor, edematous, drainage, tissue proximity is erythematous, air seen on plain imaging
Determining the appropriate level of amputation
1.
2.
3.
4.
- tissue viability (presence of ulcerations, skin anomalies, tissue deficits)
- Micro and macro - vascular circulation
- anatomy and biomechanical function
- energy expenditure and rehabilitation potential
Post op issues with amputation
1.
2.
3.
4.
- incision needs to heal before prosthetic > wear compressive sock to assist in shaping of the distal exremity (stump)
- PT to prevent contractures
- control glucose/good nutrition to allow healing
- phantom limb > gabapentin
Below knee amputation has_____________ rehab potential
___________% increase in energy expenditure. ____________% of all BKAs go into an AKA in ______ years.
Above the knee amputation has_____________ rehab potential.
__________% extra energy expenditure. Has better rates of healing.
______________ disarticulation requires 100-110% extra energy expenditure.
_____________ amputations require minimal energy expenditure, except for the _________ which is the digit most responsible for weight bearing/balance
maximal
-10-40%
-15-20%
3
less
-50-70%
hip
toe
hallux
Buerger disease (PVD) (thromboangitis obliterans) affects ______________________. It is thrombosis of _________ and ________ veins and arteries with significant ____________. Pain presents in the distal ___________,_____________ or __________. The angiography will show _________ of the distal arterial tree. _______________ is key and will halt the disease process/wound care. ______________ is not possible due to the involvement of small and distal vessels.
male cigarette smokers (middle aged)
small and medium, inflammation
ulcers, hands, feet
obliteran
smoking cessation
revascularization
PAD: Thrombotic acute risk factors are typically due to endovascular injury: ___________, _________.
1.
2.
3.
4.
5.
trauma, inflammation
smoking
HTN
DM
obesity
clotting factor disorders- only thing not for chronic
PAD: Athersclerotic acute symptoms
1.
2
3
4
5
pain/cramping
pallor
pulselessness
paresthesia (numbness/tingling, pins and needle sensation)
paralysis (severe)
-surgical ER!
(THE 5 P’s)
How is thrombotic acute (PAD) diagnosed?
-exam 5 Ps
-formal angiography in the cath lab
What is the treatment for thrombotic acute (PAD)
initiate heparin > cath lab for angiogram and intervention with chemical +/- mechanical thrombolytics > surgical thrombectomy +/- bypass depending on severity.
PVD: Aneurysmal
1.
2.
3.
4.
cerebral
aortic
ileofemoral
popliteal
________________ are the most common type of unruptured aneurysm.
Symptoms:
1.
2.
Diagnosis:
1.
Treatment:
1.
cerebral, e.g. berry aneurysm
Symptoms: HA, diziness
Dx: CTA or formal angiography
Tx: clipping or coil embolization
A popliteal aneurysm most commonly will _____________ so you need to apply ____________.
thrombose, surgicel
Risk factors associated with abdominal aortic anuerysm (AAA)
1.
2.
3.
4.
5.
The symptoms are
1.
2.
- > 65 male
- family history of AAA
- personal history of smoking
- HTN
- atherosclerotic/CV disease
Symptoms
1. tearing pain
2. onset low back pain
You want to suspect an AAA rupture in patients with:
1.
2.
Perform immediate surgical evaluation for patients with the clinical triad of:
1.
2.
3.
- sudden, acute mid-abdominal, back or flank pain, shock or syncope and pulsatile abdominal mass
- known abdominal aorta that becomes symptomatic
Triad
1. abdominal and or back pain
2. pulsatile abdominal mass
3. hypotension
Diagnosis for AAA is
1.
once confirmed, 2.________________ then 3._______________ to see how far the AAA is from the renal arteries
Treatment is
1. _________________ vs 2._______________vs 3. ______________
- abdominal u/s in work up for pulsatile mass
- CTA or formal angiography in pre-op workup
3.CT - observation (monitor with abdominal u/s yearly. if growth > every 6 months
2.open repair (anatomy incompatible with endostent > no monitoring post op) - endovascular repair (percutaneous vs traditional femoral access >life monitoring of endostent is required > ensuring no stent migration or endoleaks)
Consider immediate repair of a AAA that are expanding _____________ cm in ____________ months if the AAA is _________ cm (6cm ascending aorta)
Elective repair is indicated if greater than or equal to _____________ cm (asymptomatic)
> 0.5, 6 months, >5cm
5.5
Estimated annual risk of AAA: rupture increases with larger aneurysm size
________ cm (0%)
___________ cm (30-50%)
___________ cm is considered the best threshold for repair in a average AAA patient
<4cm
greater than or equal to 8 cm
5.5
Causes of Aortic Dissection
1.
2.
3.
4.
Symptoms/Findings
1.
2.
3.
Study of choice ______________
- deceleration accidents
- chronic high BP
- aortic aneurysm
- Marfan
Sx/findings
tearing pain
quick onset
widened aorta on XR
study of choice: CTA (tennis ball design on imaging)
Type A aortic dissection vs Type B
Type A- involves ascending aorta = affects the heart = sx emergency
Type B- involves descending/abdominal aorta=can be monitored = treat like PVD (stenting, antiplatelet therapy)
Virchows triad is a series of 3 changes that happens inside the veins which determines the formation of _______________.
They are:
1.
2.
3.
In a surgical patient there is increased risk of _________ due to immobility and extended operative times.
High risk DVT procedures: ______________ (long bone particularly) procedures involving __________ and ___________ due to _____________
venous thrombus.
- trauma to vein wall
- venous stasis
- hypercoagubility
DVT
ortho
malignancy, trauma, immobilization
Per CDC: estimated 900,00 pts yearly in US > DVT. 1/3/ to 1/2 of those patients with DVT will have long term complications such as
1.
2.
3.
edema, pain, skin changes
What are risk factors associated with DVT/PE
1.
2.
3.
4.
5.
6.
7.
8.
- sedentary (long flights/car rides)
- oral BC, hormone replacement therapy
- pregnancy
- genetic mutations: protein C or S deficiency, factor V leiden mutation, prothrombin gene mutation
- antiphospholipid antibody syndrome
- ortho sx (long bones)
- CA
- central line/catheter
Gold standard for a Pulmonary embolus
spiral CT
Gold standard for pneumonia
CXR
Gold standard for pericarditis
inflammatory markers/echo/CT
Gold standard for pneumothroax
CXR
Gold standard for MI
EKG, cardiac enzymes
Gold standard for aortic dissection
CTA
Symptoms of a pulmonary embolism
pleuritic CP, SOB, cough, tachypnea
Symptoms of DVT
extremity pain, swelling, warmth, erythema, heaviness
TYPICALLY UNILAT
Examination for DVT=
Pratts sign: ___________________________
Sigg’s sign: ____________________________
Homan’s sign:_________________________
- tenderness of veins in popliteal region
- pain in the popliteal region upon knee extension
- pain during dorsiflexion of the foot
What is the imaging of choice for a DVT?
compression ultrasound
Formation and resolution of thrombus in the vein (DVT):
inflammation of the endothelium > activation of __________ and ______________ > blood becomes _______ and clot will them form on the clot.
resolution: occurs as the bodys natural enzymes break it down overtime: __________________ = plasmin (plasminogen factor)
clotting factors and platelet aggregation, pooled
fibrinolytic enzyme
DVT/PE prophylaxis in the surgical patient
1.
2.
3.
4.
- early ambulation
- compression stockings
- pneumatic compression device
- SQ heparin or levonox (be careful in pt with renal problems)
For DVT/PE prophylaxis in a surgical patient, you want to give ______________ for ____________ days post op or until the pt is fully ambulatory.
Reversal with ____________ id heparin given within 60 min
heparin, 7-10
protamine sulfate
Why is lovenox (low molecular weight heparin not preferred?
increased bleeding risk/long half life. avoid in pts with renal insufficeicny
___________ is used to anticoagulate patients with known HIT (heparin induced thrombocytopenia)
acova, this is ok to use in renal impairment
What is the treatment for:
First occurrence PE with an identifiable risk factor: ________________
Recurrent PE: _______________
1st occurrence- anticoagulation- 3 months
recurrent- lifelong anticoagulation
Complications of a PE includes:
acute cor pulmonale > shock/death
a fib
flutter
pulmonary infarction with tissue necrosis
The treatment for DVT/PE is direct _____________________ over vitamin K antagonist therapy (e.g. coumadin) examples include:
1.
2.
oral anticoagulants
Rivaroxaban (xarelto)
apixiban (eliquis)
________________ is a clinical disorder of pain and disability resulting from chronic venous insufficiency following DVT. __________________ can be a benefit for patients with _________ DVT, symptoms for < _________ days and life expectancy of greater than or equal to ______ year. Compression stockings or in severe cases endovascular interventions (sx/ venous stenting) can help.
post thrombotic syndrome (PTS) aka post phlebitic syndrome
catheter-directed thrombolysis (CDT), illiofemoral DVT, 14, 1
Superficial thromboplebitis is a thrombus in a _________ and more _________ vein or a branch vein which can also include the UE veins. It can be spontaneous as in:
1.
2.
3.
4.
There is redness and induration along a ______________
These are treated conservatively with:
1.
2.
3.
small, distal
pregnancy
trauma
varicose veins
malignancy
superficial vein
tx:
1. warm compress
2. compression stockings/compression sleeve
3. analgesics
Not typically treated with ____________ for below the knee DVT
anticoagulation
Septic thrombophlebitis of ____________ is a life threatening emergency.
deep veins
Septic thrombophelbitis of _____________ veins (commonly seen in peripheral IV sites) can be treated with
1. ________________; ____________
superficial
IV antibiotics, staph aureus
Septic thromboplebitis can involve more severe cases with worsening of symptoms of sepsis. This will require _____________ of the affected vein followed by ______________
surgical excision
antibiotic therapy
_____________ are only considered for prevention of PE in patients with __________________ (within 1 month) whom anticoagulation is contraindicated or ineffective.
vena cava fillers
acute proximal DVT
_________________ is a rare limb threatening condition typically seen in the setting of a massive illiofemoral DVT. It is the result of total or near total thrombotic occlusion of ____________, including _________________. Severe venous congestion may result in collapse of small arteries, leading to ___________ and ____________
phlegmasia ceruela dolens
venous drainage
microvascular collaterals
arterial insufficiency
ischemia
May thurner syndrome is caused when the _____________ vein is compressed by the ___________ artery which increases the risk of DVT in the left extremity. This mostly affects ____________ but can affect men. It is diagnosed by ___________ and treated with ____________ to the left common iliac vein.
left illiac, right iliac
women (esp pregnant)
venography
stenting
Explain Thoracic Outlet syndrome (TOS)
BV/nerves between clavicle/1st rib compressed > shoulder/neck numbness and DVT
Common causes are physical trauma, repetitive injuries from job/sports
Dx: absence of pulse with arm in full abduction > venography to confirm
Tx: PT > rib resection (1st rib or extra rib)
Etiology for Varicose veins
1.
2.
3.
4.
Patho: ____________
- obesity
- hereditary
- pregnancy
- standing long hours
patho: faulty valves > stagnant blood (blood doesnt go into the opposite direction)
What are the s/s of varicose veins?
1.
2.
3.
4.
5.
What is the first line treatment?
What is the prognosis?
- aching legs
- spider veins
- ropey appearance of LE veins
- venous stasis ulcer!! due to long term inflammation
- general edema
first line: conservative tx
-leg elevation
-elastic support stocking (pressure-graded)
prognosis: NOT a limb threatening condition it is lifestyle limiting and sometimes cosmetic condition. surgical = better outcomes
What is the use for unna boot therapy?
its a compression dressing with zinc oxide paste thats applied uniformly to entire bandage. it helps ease skin irritation and keeps the area moist. The zinc promotes healing within the wound site and makes it useful for burns and ulcers
A surgical site infection is one that occurs at or near the surgical incision. Superficial/subq lasts up to __________ days. Deep/fascia/muscle up to __________ days. Organ is up to __________days. We are looking for things like:………..
The risk factors for surgical site infections are
1.
2.
3.
4.
30, 90, 90.
abscess/purulent drainage, severe pain and localized edema, heat, positive cultures
increased age
smokers
diabetes
heavy ETOH
Which medications are given for antibiotic prophylaxis?
ancef (cefazoline) clindamycin, Vanco
What is the treatment of an established surgical site infection?
Conservative
1.
Oral/IV antibiotics
1.
Surgical management:
1
2
3
- topical wound care
- culture purlulent discharge > start empiric therapy
- I &D
- Placement of surgical drains (jackson pratt)
- negative pressure wound therapy (wound vac)
Excessive wound fluid is an issue, the normal skin around the wound opening should be protected by skin barriers such as
1.
2.
3.
______________ or foam dressings are useful for highly draining wounds and in severe cases a negative pressure dressing
zinc oxide
petroleum jelly
oil film-forming skin barriers such as skin prep or cavillon
calcium alginate
Most of the lesions of an arterial emboli originate from the __________ system. The _____________ artery has no branching therefore it goes straight to the brain and will cause a stroke.
carotid
internal carotid
The circle of willis is formed by two group of arteries:
1.
2.
These arteries provide the anterior and posterior circulation of the brain respectively.
Internal carotid arteries
2 vertebral arteries
3 Major structures included in the carotid sheath:
1
2
3
_______________ = not included in the vascular sheath
1 internal carotid artery
2 internal jugular vein
3 vagus nerve CN X
external carotid artery
Clinical findings of a stroke
1.
2.
3.
4.
- carotid bruit- turbulent
- weakness: unilat and symptoms opposite of the cerebral hemi below the optic chiasm
- Visual changes (amaurosis fugax) temporary vision loss due to lack of blood flow to the retina. retinal detachment (persistent loss of vision)
typically unilat and same side as cerebral hemisphere - Expressive aphasia- difficulty with word finding/garbled speech
What is the first imaging study used for evaluation of carotid arterial disease?
carotid duplex
Which is the best confirmatory study for carotid stenosis?
CTA
Risk factors for CVA
1.
2.
3.
4.
5.
6.
7.
8.
family history, arterial hypertension, diabetes mellitus, dyslipidemia, heart disease, cigarette smoking, excessive alcohol intake, obesity.
For cerebrovascular disease, you want to intervene….
Asymptomatic and stenosis greater than _________%
Symptomatic and greater than ____________%
Start antiplatelet therapy (either aspirin or plavix) NOT BOTH
Prevention: _______________
If 50% stenosis start at _________________
Carotid Endarterectomy: …..
Carotid Stenting: ……
75
60
ASA 81mg/day
ASA 325 mg/day
Carotid Endarterectomy – go in the artery and pulls out the plaque
Carotid stent – only when you had prior radiation to the neck or neck surgery
Carotid Endarterectomy (CEA) complications
1.
2.
3.
4.
5.
6.
Facial nerve palsy (facial droop)
Vagus nerve injury
CVA
Hypoglossal nerve injury (tongue deviation/numbness)
Recurrent laryngeal nerve injury (hoarseness)
Bleeding
Carotid Stenting Complications
1.
2.
CVA
Bleeding
Mesenteric Ischemia can be acute (typically thrombotic) or chronic (typically atherosclerotic over time) symptoms are _________________ and ___________________. This occurs approx 20-30 min after eating and the pain waxes and wanes, will resolve after 1-3 hours. Can lead to ______________.
Gold standard imaging:
Tx is typically:
post prandial abdominal pain
unintentional weight loss
bowel necrosis
CTA abdomen
angioplasty/stenting
Hemodialysis access is when worsening in kidney function that is seen by elevation in __________________ and ________________ (____________) It requires either peritoneal dialysis or hemodialysis.
Peritoneal dialysis:……
Hemodialysis: the _______________ is permanent…….
What are the pros and cons to an arteriovenous fistula?
BUN/creatinine
electrolyte dysfunction (hyperkalemia)
Peritoneal dialysis: pts catheter placed in abdominal peritoneum, can be done at home
Hemodialysis: arteriovenous fistula
connecting a patients vein with their own artery. takes 8-10 weeks to mature.
Pros: low infection risk, long patency
Cons: long maturation times
if need dialysis > reliant on external catheter > infection
continued maturation > aneurysmal fistulas
What is an arteriovenous graft (AVG) and what are its pros/cons?
(AVG) is created by connected a synthetic tube to a patients vein/artery. Can be done in lower/upper part of the arm. DOES NOT REQUIRE MATURATION generally placed in the upper arm
Pros: heals within days
Cons: higher risk for infection, low primary patency rate
Which one is preferred? An arteriovenous fistula or an arteriovenous graft?
arteriovenous fistula
