Diseases of the arteries and veins Flashcards
PERIPHERAL ARTERIAL DISEASE
Etiology:
- atherosclerosis= diffuse arterial damage with discontinuous lesions
- pathophysiology – similar to ischemic heart disease – formation of the atheromatous plaque
PERIPHERAL ARTERIAL DISEASE
Risk Factors :
- smoking
- diabetes mellitus
- dyslipidemia
- HTN
-Manifestations differ according to the origin of atheroma:
Cerebral circulation: TIA, amaurosis fugax, vertebrobasilar circulatory insufficiency
Carotid arteries
Coronary arteries
Renal arteries 🡪 HTN, Renal Insufficiency
Mesenteric arteries : enteromesenteric infarction
-Inferior limbs: chronic ischemia (intermittent claudication) acute ischemia
Peripheral Arterial Disease
1) Factors contributing to the clinical presentation in PAD
Pathophysiological mechanism
Peripheral Arterial Disease
2) Hemodynamic changes:
the atheromatous plaque progressively decreases the vascular lumen
> 70% 🡪 critical stenosis
<70% 🡪 symptoms at different
Peripheral Arterial Disease
3) Thrombotic changes:
- Occlusion of a critical stenosis
- Plaque fissure/ rupture with superimposed thrombosis
- Plaque instability
Peripheral Arterial Disease
4) Thromboembolic changes
- AFib
- Intracardiac thrombi
- Migrated
Collateral circulation develops in 1) \_\_\_\_by 2) \_\_\_ and 3) \_\_\_\_\_between the 4) \_\_\_ and 5) \_\_\_\_\_ of the artery. - Initial presentation - Target arteries: - 2 clinical entities
1) ischemic conditions
2) angiogenesis
3) dilation of small preexistent vascular anastomosis
b/w the pre and poststenotic regions
Initial presentation:
- Gradual onset – slow progression with collateral formation
- Sudden onset – acute ischemia
Target arteries: Inferior limbs: - Aortoilliac segment - Femuropopliteal segment - Infrapopliteal segment
Lesions are variable, asymmetrical.
2 clinical entities:
1. Intermittent claudication
2. Critical ischemia
Intermittent Claudication
Ischemic pain of the inferior limbs’ muscles (muscular cramps) triggered by walking and paused at rest,
reappears when effort is resumed; atypical presentation in the elderly population
Pain location: depending on the obstructed site (buttock, thigh, calf, foot)
Onset after a certain walking distance = claudication index
- Repetitive pattern – determined by colateral development
Leriche –Fontaine Classification
Stage I Absence of ischemic symptoms; diagnosis
by clinical examination/ workup
Stage II A Intermittent claudication when walking
> 200m
II B Intermittent claudication when walking
< 200m
Stage III Intermittent claudication when walking
< 200m
Stage IV Ischemic symptoms at rest; pain + trophic cutaneous lesions: ulcers, necrosis, gangrene
Patient Examination
- presence of other atherosclerotic lesions
- diminished/ absent pulses – bilateral palpation,
observe the site where pulses became weaker - murmurs – account for the flux turbulence
- decreased temperature
- palour – when elevating the inferior limb at an
angle of 60-75◦ + moving of the ankle = Buerger sign - time needed for the legs to regain colour
N= 10 SEC
25-30 SEC = Moderate Obstruction
>40 SEC = Severe Obstruction
- muscular atrophy
- decreased hair growth, brittle nails
- ischemic ulcers: irregular margins, painful, usually
located on the dorsal aspect of the foot, as well as
pretibial
Workup
- Ankle-Brachial Index (ankle SBP/ brachial SBP)
- N>0,9;
- Mild to Moderate PAD: 0,41-0,90
- Severe PAD: <0,41
- Correlates with cardiovascular risk - Vascular Ultrasound + Doppler examination: determines the variation of the blood flow velocity
IVUS (IntraVascularUltraSound) – imaging of the
endovascular arterial wall
- Oscillometry
- Arteriography – criterion standard arterial imaging study used to estimate severity and location of the obstruction, permeability of the distal vascular bed and of the collaterals, as well as the optimal type of revascularization procedure needed
Differential Diagnosis
- Lumbar Discopathy Pain
- Chronic Venous Insufficiency Pain
- Muscle Cramps
- Joint Pain
Diabetic Foot
(Diabetic Microangiopathy)
5-10% of patients with intermittent claudication have DM
Pathophysiology:
- Arterial calcifications
- Depressed immunity (cellulitis, gangrene, osteomyelitis)
- Multisystemic arterial disease (cerebral, coronary, peripheral)
- Distal vascular disease
Diabetic Foot
Symptoms:
- Persistent pain
- Redness (infection)
- Swelling (inflammation/infection)
- Claudication
- Poor hair growth
- Hard shiny skin on the legs
- Numbness
- Ulcers
LERICHE SYNDROME
Chronic aortoiliac occlusion - Femural pulse absent bilaterally - Bilateral inferior limb pain, especially in the superior segment - Muscular atrophy
Critical Peripheral Ischemia
Pain
- at night, at rest
- partialy suppressed by painkillers
- associating trophic lesions: ulcers, gangrene
Duration > 2 weeks
Ankle-Brachial Index < 0.5 (ankle SBP < 50 mmHg)
Critical Peripheral Ischemia
Treatment
MEDICAL
MEDICAL
- Smoking cessation
- Diabetes, HTN, dyslipidemia control
- Antiplatelet Agents: Aspirin, Clopidogrel – used in maintaining patency of peripheral grafts, as well
Critical Peripheral Ischemia
Treatment \
SURGICAL
SURGICAL, after arteriography
Indications: pain triggered by effort, limiting the patient,
threat of amputate
1) Transluminal percutaneous angioplasty (balloon/ stent)
2) Endarterectomy
3) Bypass
(internal saphenous graft / artificial prosthesis-Dacron/ biological prosthesis)
4) Lumbar sympathectomy (limited use; resection of the
2nd, 3rd, 4th group of lymph nodes from the lumbar
sympathetic lymphatic network – for sympathetic
denervation and inhibition of vasoconstrictor impulses)
5) Amputation
CRONIC ISCHEMIA OF THE SUPERIOR LIMBS
Subclavian artery – most frequently affected
Causes:
1) Atherosclerosis
2) Cervical Rib
3) Takayasu disease
Clinical presentation:
- Superior limb claudication - rare
- Atheroembolism 🡪 blue finger syndrome (caused by small emboli in the finger)
BUERGER’S DISEASE
THROMBANGITIS OBLITERANS
- Inflammatory disease different from atherosclerosis
- Genetic affiliation: male predominance, smokers, 20-40 y.o.
- Affects the veins as well (superficial thrombophebitis)
Biologically: hypercoagulability due to immunological processes
Angiographically: distal lesions, below the knee (small and medium caliber arteries)
Histopathologically: inflammatory lesions, panarteritis/panphlebitis+thrombosis of the vascular wall without necrosis
BUERGER’S DISEASE
(THROMBANGITIS OBLITERANS)
Treatment options:
- Smoking cessation
- Prostaglandins (PGI2, PGI2)
- Sympathectomy
PERIPHERAL ACUTE ISCHEMIA
= sudden obstruction of the blood flow
Peripheral acute ischemia
causes
- Thrombotic occlusion of an arterial segment with preexistent stenosis
- Thrombembolism:
- AFib
- Intraventricular thrombi
- Artificial valves
- Valvular vegetations
- Aortic wall thrombi
- Paradoxical thrombi – originating in the profound venous system in the setting of a patent foramen ovale
- Intense arterial spasm
- Trauma
- Iatrogen
PERIPHERAL ACUTE ISCHEMIA
Symptoms – 6 ”P”s
- Pain with sudden onset
- Pallor (distal to the obstruction site)
- Pulseless
- Paresthesias
- Paralysis
- Perishing with cold
The site where the pulse is no longer palpable and the temperature is lower is situated one joint distally to the obstruction.
Special presentation:
- Aortoiliac acute occlusion
- Superior limb acute arterial ischemia
PERIPHERAL ACUTE ISCHEMIA
Treatment:
iv Heparin bolus + i.v. perfusion
- Limits the expansion of the thrombus
Protects the collaterals
- if symptoms persist in spite of the repermeabilisation of the lumen = thrombus extended to the collaterals
Trombolysis
Vascular surgery
- Embolectomy – Fogarty balloon angioplasty – time frame 4-6 hours
- Endarterectomy
- By-pass
+ anticoagulant treatment post-op to prevent arterial re-occlusion and thrombotic venous complications
VASCULAR FUNCTIONAL DISORDERS
(arterial circulation disturbances in the extremities caused by vasomotricity alteration)
RAYNAUD PHENOMENA
- Typical sequence: Vasospasm 🡪 Pallor Deoxygenation 🡪 Cyanosis Reactive Hyperemia 🡪 Redness - Appears when exposed to cold temperature - Transient, paroxismal ischemia Primary R.F. = Raynaud’s Disease Secondary R.F. = Raynaud’s Syndrome
Raynaud’s Syndrome
Associated with:
- Professional microtrauma
- Carpal Tunnel Syndrome
- Cervical Rib Syndrome
- Collagenosis: Scleroderma, SLE, Reumatoid Arthritis
- Thrombangeitis Obliterans
- Ergotamine/Led Poisoning
- Hematological disease (cryoglobulinemia)
Raynaud’s Syndrome
Complications:
- Sclerodactily
- Nail ulcers – healing with small scars
Raynaud’s Syndrome
Treatment:
- Calcium Channel Blockers
- Prostaglandins
ACROCYANOSIS
= symmetrical cyanosis of the hands or
–rarely- of the feet
- low local temperature
- hyperhydrosis – variable
- triggered by cold temperatures
- abnormal vasoconstriction of distal arterioles
(local sensitivity to cold temperature, sympathetic hyperstimulation)
Vasospasm 🡪 Capillary Dilation 🡪 Hemoglobin Desaturation
- 80% of cases = Women, frequently during puberty
VENOUS DISEASE
= thrombus in the venous lumen
Classification:
- Superficial (SVT)
- Deep (DVT)
DEEP VEIN THROMBOSIS
DEEP VEIN THROMBOSIS
Causes: Virchow’s Triad:
1. Venous Stasis Right HF - Immobility - Pregnancy - Varicose Veins & Chronic Venous Insufficiency - Stasis – long trips
- Venous wall injury
- Venous catheters
- Irritant chemical substances - Hypercoagulability/ platelet hyperactivity
- Protein C, S deficit
- Low AT III (heparin’s cofactor I)
- High PAI- I (plasminogen activator inhibitor)
- Antiphospholipid Antibodies
DEEP VEIN THROMBOSIS
RISK FACTORS
- Trauma (Surgical/ Non-surgical)
- Prolonged Immobility
- Age > 60 years
- Neoplasm
- Right HF
- Varicose Veins, Postthrombotic syndrome
- Obesity
- Sepsis
- Oral Contraceptives (estrogen)
- Pregnancy
- Hypercoagulable states
DEEP VEIN THROMBOSIS
Signs & Symptoms Pain - worsened by : - Walking - Orthostatism - Palpation - Edema - Dilation of the superficial venous network - Phlegmatia alba dolens/ coerulea dolens
DVT - Types
Superior limbs:
- idiopathic: violent effort with arm abduction
- Secondary to :
- surgical procedures in the near proximity
- subclavian vein catheter
Inferior vena cava:
- rarely, usually by extension of an iliofemural thrombosis
- Bilateral edema of the inferior limbs
- Prominent venous network: inferior abdominal wall, lumbar region, proximal segment of the thighs
Superior vena cava:
- Following a mediastinal syndrome
Complication: Massive pulmonary embolism
DVT WORKUP
- Phlebography with contrast
- Radioisotopic venography (serumalbumin macroagregates marked with Tc99 or marked red blood cells)
- CT, MRI: especially for abdominal vein thrombosis
- Ultrasound with compression
- Color Doppler ultrasound
DVT
COMPLICATIONS + TREATMENT
COMPLICATIONS:
- Pulmonary Embolism
- Postthrombotic syndrome
TREATMENT:
- Anticoagulant
- Fibrinolytic
SUPERFICIAL VEIN THROMBOSIS
- Inflammatory lesion of the subcutaneous venous walls
- Usually does not embolise
SUPERFICIAL VEIN THROMBOSIS
- Causes
- Signs & Symptoms
Varicose veins
- Irritant substances administered iv
- Venous catheters
- Insect bytes
- Infections from the surrounding areas (cellulitis, limphangitis)
- Thrombangeitis obliterans, vasculitis
Signs & Symptoms
- Indurated venous contour, painful spontaneously and on palpation, with local signs of inflammation
SVT
1. Phlebitis migrans
- Consequent phlebitis in different venous territories
- Types:
- Idiopathic
- Secondary: digestive/respiratory neoplasm,
inflammatory diseases, thrombangeitis obliterans
SVT
2. Mondor disease
- thrombosis of the thoraco-epigastric veins
- usually on the lateral aspect of the thorax
- unknown cause
- frequent after mastectomy
POSTTHROMBOTIC SYNDROME
= hypertension of the deep venous system, secondary to DVT cured with
sequele
- Frequently accompanied by lymphatic insufficiency.
POSTTHROMBOTIC SYNDROME
Signs & Symptoms
- Edema
- Subcutaneous vein dilation (unlike idiopathic varicose veins, where the deep venous network is normal, in secondary venous dilation the veins
don’t empty as soon as the inferior limb is elevated) - Trophic cutaneous lesions
-atrophic, shiny skin
-frequent eczema - Petechie formed by extravasation of red blood cells
turn into brown patches= dermatitis ocra - Calf ulcers – on the antero-internal aspect of the calfs, supra maleolar
POSTTHROMBOTIC SYNDROME
Prophylaxis + Treatment
Prophylaxis & Treatment
- external compression
- postural drainage
