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Semiology second semester > Diseases of the arteries and veins > Flashcards

Diseases of the arteries and veins Flashcards

1
Q

PERIPHERAL ARTERIAL DISEASE

Etiology:

A
  • atherosclerosis= diffuse arterial damage with discontinuous lesions
  • pathophysiology – similar to ischemic heart disease – formation of the atheromatous plaque
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2
Q

PERIPHERAL ARTERIAL DISEASE

Risk Factors :

A
  • 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
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3
Q

Peripheral Arterial Disease

1) Factors contributing to the clinical presentation in PAD

A

Pathophysiological mechanism

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4
Q

Peripheral Arterial Disease

2) Hemodynamic changes:

A

the atheromatous plaque progressively decreases the vascular lumen

> 70% 🡪 critical stenosis
<70% 🡪 symptoms at different

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5
Q

Peripheral Arterial Disease

3) Thrombotic changes:

A
  • Occlusion of a critical stenosis
  • Plaque fissure/ rupture with superimposed thrombosis
  • Plaque instability
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6
Q

Peripheral Arterial Disease

4) Thromboembolic changes

A
  • AFib
  • Intracardiac thrombi
  • Migrated
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7
Q 
Collateral circulation develops in 1) \_\_\_\_by 2) \_\_\_ and 3) \_\_\_\_\_between the 4) \_\_\_ and 5) \_\_\_\_\_
of the artery.
- Initial presentation
- Target arteries:
- 2 clinical entities
A

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

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8
Q

Intermittent Claudication

A

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

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9
Q

Leriche –Fontaine Classification

A

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

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10
Q

Patient Examination

A
  • 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
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11
Q

Workup

A
  1. 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
  2. Vascular Ultrasound + Doppler examination: determines the variation of the blood flow velocity

IVUS (IntraVascularUltraSound) – imaging of the
endovascular arterial wall

  1. Oscillometry
  2. 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
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12
Q

Differential Diagnosis

A
  1. Lumbar Discopathy Pain
  2. Chronic Venous Insufficiency Pain
  3. Muscle Cramps
  4. Joint Pain
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13
Q

Diabetic Foot

A

(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
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14
Q

Diabetic Foot

Symptoms:

A
  • Persistent pain
  • Redness (infection)
  • Swelling (inflammation/infection)
  • Claudication
  • Poor hair growth
  • Hard shiny skin on the legs
  • Numbness
  • Ulcers
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15
Q

LERICHE SYNDROME

A 
Chronic aortoiliac occlusion
- Femural pulse absent bilaterally
- Bilateral inferior limb pain, especially in the
superior segment
- Muscular atrophy
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16
Q

Critical Peripheral Ischemia

A

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)

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17
Q

Critical Peripheral Ischemia
Treatment
MEDICAL

A

MEDICAL

  • Smoking cessation
  • Diabetes, HTN, dyslipidemia control
  • Antiplatelet Agents: Aspirin, Clopidogrel – used in maintaining patency of peripheral grafts, as well
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18
Q

Critical Peripheral Ischemia

Treatment \
SURGICAL

A

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

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19
Q

CRONIC ISCHEMIA OF THE SUPERIOR LIMBS

A

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)
20
Q

BUERGER’S DISEASE

THROMBANGITIS OBLITERANS

A
  • 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

21
Q

BUERGER’S DISEASE
(THROMBANGITIS OBLITERANS)
Treatment options:

A
  • Smoking cessation
  • Prostaglandins (PGI2, PGI2)
  • Sympathectomy
22
Q

PERIPHERAL ACUTE ISCHEMIA

A

= sudden obstruction of the blood flow

23
Q

Peripheral acute ischemia

causes

A
  1. Thrombotic occlusion of an arterial segment with preexistent stenosis
  2. Thrombembolism:
  3. 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
24
Q

PERIPHERAL ACUTE ISCHEMIA

Symptoms – 6 ”P”s

A
  • 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
25
Q

PERIPHERAL ACUTE ISCHEMIA

Treatment:

A

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

26
Q

Trombolysis

Vascular surgery

A
  1. Embolectomy – Fogarty balloon angioplasty – time frame 4-6 hours
  2. Endarterectomy
  3. By-pass

+ anticoagulant treatment post-op to prevent arterial re-occlusion and thrombotic venous complications

27
Q

VASCULAR FUNCTIONAL DISORDERS

A

(arterial circulation disturbances in the extremities caused by vasomotricity alteration)

28
Q

RAYNAUD PHENOMENA

A 
- 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
29
Q

Raynaud’s Syndrome

A

Associated with:

  • Professional microtrauma
  • Carpal Tunnel Syndrome
  • Cervical Rib Syndrome
  • Collagenosis: Scleroderma, SLE, Reumatoid Arthritis
  • Thrombangeitis Obliterans
  • Ergotamine/Led Poisoning
  • Hematological disease (cryoglobulinemia)
30
Q

Raynaud’s Syndrome

Complications:

A
  • Sclerodactily

- Nail ulcers – healing with small scars

31
Q

Raynaud’s Syndrome

Treatment:

A
  • Calcium Channel Blockers

- Prostaglandins

32
Q

ACROCYANOSIS

A

= 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
33
Q

VENOUS DISEASE

A

= thrombus in the venous lumen

Classification:

  • Superficial (SVT)
  • Deep (DVT)
34
Q

DEEP VEIN THROMBOSIS

A

DEEP VEIN THROMBOSIS

Causes: Virchow’s Triad:

1. Venous Stasis
Right HF
- Immobility
- Pregnancy
- Varicose Veins & Chronic Venous Insufficiency
- Stasis – long trips
  1. Venous wall injury
    - Venous catheters
    - Irritant chemical substances
  2. Hypercoagulability/ platelet hyperactivity
    - Protein C, S deficit
    - Low AT III (heparin’s cofactor I)
    - High PAI- I (plasminogen activator inhibitor)
    - Antiphospholipid Antibodies
35
Q

DEEP VEIN THROMBOSIS

RISK FACTORS

A
  1. Trauma (Surgical/ Non-surgical)
  2. Prolonged Immobility
  3. Age > 60 years
  4. Neoplasm
  5. Right HF
  6. Varicose Veins, Postthrombotic syndrome
  7. Obesity
  8. Sepsis
  9. Oral Contraceptives (estrogen)
  10. Pregnancy
  11. Hypercoagulable states
36
Q

DEEP VEIN THROMBOSIS

A 
Signs & Symptoms
Pain - worsened by : 
- Walking
- Orthostatism
- Palpation
- Edema
- Dilation of the superficial venous network
- Phlegmatia alba dolens/ coerulea dolens
37
Q

DVT - Types

A

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

38
Q

DVT WORKUP

A
  1. Phlebography with contrast
  2. Radioisotopic venography (serumalbumin macroagregates marked with Tc99 or marked red blood cells)
  3. CT, MRI: especially for abdominal vein thrombosis
  4. Ultrasound with compression
  5. Color Doppler ultrasound
39
Q

DVT

COMPLICATIONS + TREATMENT

A

COMPLICATIONS:

  • Pulmonary Embolism
  • Postthrombotic syndrome

TREATMENT:

  • Anticoagulant
  • Fibrinolytic
40
Q

SUPERFICIAL VEIN THROMBOSIS

A
  • Inflammatory lesion of the subcutaneous venous walls

- Usually does not embolise

41
Q

SUPERFICIAL VEIN THROMBOSIS

  • Causes
  • Signs & Symptoms
A

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

42
Q

SVT

1. Phlebitis migrans

A
  • Consequent phlebitis in different venous territories
  • Types:
    - Idiopathic
    - Secondary: digestive/respiratory neoplasm,
    inflammatory diseases, thrombangeitis obliterans
43
Q

SVT

2. Mondor disease

A
  • thrombosis of the thoraco-epigastric veins
  • usually on the lateral aspect of the thorax
  • unknown cause
  • frequent after mastectomy
44
Q

POSTTHROMBOTIC SYNDROME

A

= hypertension of the deep venous system, secondary to DVT cured with
sequele
- Frequently accompanied by lymphatic insufficiency.

45
Q

POSTTHROMBOTIC SYNDROME

Signs & Symptoms

A
  • 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
46
Q

POSTTHROMBOTIC SYNDROME

Prophylaxis + Treatment

A

Prophylaxis & Treatment

  • external compression
  • postural drainage

Semiology second semester (13 decks)

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