Exam 1 - Peripheral vascular dz packet Flashcards
Possible S/Sx of arterial occlusion in an extremity? (8)
Numbness, tingling, pain, weakness, coldness, pallor or “mottling” of skin, motor/sensory/reflex alterations, decreased pulse amplitude distal to occlusion
What is “dusky cyanosis”?
Mixed rubor and cyanosis
What is an embolus?
Mass, such as detached blood clot/foreign body/air bubble that travels through bloodstream
What is an embolism?
embolus that lodges so as to obstruct or occlude a blood vessel
What are emboli most often associated with?
Ischemic heart disease
Where do cardiogenic emboli tend to lodge?
In the bifurcations of major arteries
Where do the majority of emboli lodge?
Aortic bifurcation and larger arteries of lower extremities
What are splinter hemorrhages indicative of?
Infective endocarditis
What is a thrombus?
Blood clot formed within a blood vessel that remains attached to its place of origin
Where do thrombi usually occur?
At sites narrowed by atherosclerotic plaque
What are acute arterial thromboses often precipitated by?
Inflammation of the arterial wall
What does Peripheral arterial disease (PAD) refer to?
arterial insufficiency in the lower extremities
What is PAD usually due to?
atherosclerotic plaque
Who is PAD much more common in?
Diabetics
Causes of subclavian artery occlusion? (4)
- cardiogenic emboli 2. thrombus formation 3. arterial thoracic outlet syndrome 4. subclavian steal syndrome
How common is arterial thoracic outlet syndrome?
Relatively uncommon (1%)
What is a huge problem with artertial thoracic outlet syndrome?
False positives
What is subclavian steal syndrome due to?
Usually due to acquired atherosclerotic occlusion of subclavian artery PROXIMAL to vertebral artery
How does subclavian steal syndrome usually manifest?
As an exercise-induced “theft” of blood from the ipsilateral vertebral artery
S/Sx of subclavian steal syndrome?
involved arm SBP is >20 mmHg lower, decreased pulse amplitude, “claudication” symptoms of weakness/fatigability/pain
What does coarctation of the aorta lead to?
Upper extremity hypertension and lower extremity hypotension/lower extremity “pulse lag”
What is “infantile” aortic coarctation?
Pre-ductal
What is “adult” aortic coarctation?
Post-ductal
Common first symptoms of aortic coarctation?
Decreased exercise tolerance and easy fatigability
How often do abdominal aortic aneurysms occur in the US?
5 to 8 % of people over 60
How do most pts with AAA present?
Asymptomatic
What is the normal diameter of infrarenal/supraumbilical aorta?
2 cm
What is the normal aortic pulsation?
Brief, succinct, short duration
What is the only physical exam procedure with demonstrated value in the detection of AAAs?
Palpation
What is the anticipated increase in aortic diameter with increasing age/male gender/increasing body mass?
> 2cm but < 3 cm
Technical definition of AAA?
infrarenal aorta that is > 3 cm in diameter
When should there be clinical concern regarding an AAA?
Aneurysm > 4 cm in diameter
How many patients are AAAs diagnosed in before rupture?
One-third
Non-modifiable risk factors for AAA?(3)
Advancing age, male gender, ethnicity
Modifiable risk factors for AAA? (3)
Cigarette smoking, HTN, Atherosclerotic diseases
Potential AAA complications? (4)
- “extension” of aneurysm to renal or common iliacs 2. acute lower extremity arterial insufficiency 3. “impending” rupture (expansion or controlled bleed) 4. Overt rupture (hemorrhage, shock, death)
What are significant findings on auscultation of abdominal aorta?
Systolic bruits
are abdominal bruits well-localized?
No
How would you detect an AAA by palpation?
expansile, pulsatile mass
What is an abnormal aneurysmal pulsation?
Prolonged, diffuse, long duration
What 2 factors affect the ability to examine a pt for suspected AAA?
Size of pt, size of AAA
How much does an AAA typically grow in a year?
0.2-0.8 cm in diameter per year
How common is rupture of AAA under 4 cm?
Uncommon
How common is rupture of AAA > 7 cm?
19-25% annual rate of rupture
What is the modality of choice for monitoring smaller aneurysms?
Diagnostic ultrasound
What do the symptoms and time-line of an AAA rupture depend on?
type of rupture
S/Sx of “impending” rupture? (4)
- flank pain of sudden onset (may mimic kidney stone) 2. back pain of sudden onset (may mimic herniated disc) 3. abdominal pain of sudden onset 4. pain usually unrelieved by changes in position
S/Sx of “frank” rupture?
shock and death
What do acute/frank ruptures almost always follow?
Slow bleed/”impending” rupture
What is PAD most commonly associated with?
Atherosclerosis
What does PAD indicate a high risk for?
Cardiovascular morbidity and mortality
Non-modifiable risk factors for PAD? (2)
Being over 60, male gender
Modifiable risk factors for PAD? (3)
- Smoking 2. HTN 3. Diabetes
How much more common is PAD in diabetics than non-diabetics?
3-5 times more common
What are the “classic” findings for PAD based on?
Unilateral disease
In PAD, which is more common, bilateral aortoiliac “segment” or unilateral femorpopliteal “segment”?
unilateral femoropopliteal segment
In PAD, is bilateral disease progressive or not?
Most often progressive
In PAD, is unilateral disease progressive or not?
Less often progressive
Site of claudication in unilateral PAD?
Calf muscles and foot
Which pulses are absent in unilateral PAD?
Popliteal and foot pulses
Trophic changes in PAD (bilateral vs unilateral)?
Bilateral = minimal trophic changes unilateral = distinct changes
Findings on adjunct procedures with unilateral PAD?
Delayed venous filling, dependent rubor, etc
What is an essential component of treatment for PAD?
Risk factor modification
How many pts have “asymptomatic” PAD?
50%
What type of leg pain do PAD pts have on exertion?
“non-claudication” leg pain
How many PAD pts have “peripheral arterial occlusive disease” and claudication?
40%
What is the “classic” indicator of symptomatic PAD?
Intermittent claudication
Where is ischemic pain classically seen in PAD?
the calf
What does the distribution of symptoms of PAD depend on?
level of occlusion
Typical history/pattern of PAD?
Fixed threshold distance, short tolerance distance, brief refractory period
What is fixed threshold distance?
onset of pain after walking a short, PREDICTABLE distance
What is short tolerance distance?
Pt cannot continue walking due to pain
What is brief refractory period?
pain decreases almost as soon as pt rests
What type of atherosclerosis does intermittent claudication indicate?
“high grade” atherosclerosis
What percentage of PAD pts have critical leg ischemia?
10%
What do rest pain, ulcers, and gangrene indicate in PAD pts?
very advanced disease
3 indicators of PAD in symptomatic leg?
- absence of dorsal pedal and post tib pulses 2. wounds/sores on foot 3. presence of asymmetric foot coolness
What is neurogenic claudication?
BILATERAL leg heaviness/tingling makes pt want to stop walking
How is neurogenic claudication different from PAD?
bilateral, pulses usually intact, threshold distance varies day to day, tolerance distance varies, refractory period varies
PAD exam: what should normal venous filling time be?
<20 seconds
PAD exam: what should normal capillary refill time be?
<5 seconds
What is the ankle-arm index (AAI)?
Ankle BP / Arm BP
Normal AAI range?
1.0-1.3
Where do most pts with arterial intermittent claudication have AAIs?
0.5-0.8
What does AAI correlate to?
Distance pt can walk symptom-free
How far can pt walk with AAI of 0.6-0.8?
1-2 blocks
How far can pt walk with AAI of 0.4-0.6?
Less than one block
How far can pt walk with AAI of <0.4?
Rest pain, arterial ulcers, gangrene = advanced disease
What is the most important risk factor for PAD?
smoking
What is the most effective tx of PAD?
exercise training
What is Raynaud’s phenomenon?
reversible vasospastic ischemia of peripheral arterioles, most often seen in fingers
Classic tri-phasic color change of Raynauds?
Pallor, cyanosis, rubor
How many color changes are seen in the common presentation of Raynauds?
At least 2
How defined is the area involved in Raynauds?
Well defined/well demarcated
Where does demarcation of Raynauds usually occur?
Joint lines
What is the vasospasm/pallor/cyanosis of Raynauds usually accompanied by?
numbness/tingling
What does rubor indicate in Raynauds?
Circulation has been restored
Is Raynauds a primary or secondary condition?
Can be either
What is primary raynauds?
Idiopathic vasospasm
Which hand is usually affected with primary raynauds?
BOTH
How long do primary attacks of Raynaud’s last?
30-60 minutes
Which gender is Raynauds more common in?
Women
Common triggers of Raynauds? (3)
- cold environments 2. mental stress 3. smoking
What percentage of primary Raynauds pts respond to conservative care?
90%
What should primary Raynaud’s pts be monitored for? (4)
- connective tissue diseases 2. capillary nailfold changes 3. telangectasia 4. rashes
What is a possible treatment for Raynauds that may lower number of attacks?
Gingko biloba
What should you consider if a Raynaud’s pt has changes in the nail fold?
autoimmune diseases
Is secondary Raynauds unilateral or bilateral?
More often unilateral
What is secondary Raynauds often associated with?
autoimmune diseases
What syndromes may predispose to Raynauds, but rarely lead to nail fold changes? (2)
carpal tunnel syndrome or thoracic outlet syndrome
What should you look for in a digit exam for Raynauds pts? (4)
- telangiectasia 2. persistant cyanosis or ulcers 3. sclerodactyly 4. peripheral pulses
What is the third most common CV disease in the US?
Deep vein thrombosis
What can DVT lead to if untreated?
pulmonary embolism
What is Virchow’s triad?
- venous stasis 2. hypercoagulability 3. vessel wall inflammation
Why is Virchow’s triad important?
all known clinical risk factors for DVT/pulmonary emboli have their basis in one or more elements of the triad
What is venous thrombophlebitis?
secondary inflammatory changes to vein
What can thrombophlebitis lead to?
Deformation of the venous valves
Classic risk factors for DVT? (4)
- Family Hx 2. venous stasis 3. Recent major surgery or trauma 4. active cancer/chemotherapy
Why is DVT hard to diagnose?
Asymptomatic in early stages
Which vein is involved in 80% of pts with confirmed DVT?
popliteal vein
Are proximal or distal DVTs more threatening?
Proximal have much higher incidence of pulmonary embolism
Which vein is involved in about 20% of DVT pts?
Posterior tibial vein
What are commonly reported findings in cases of suspected DVT? (6)
pain, swelling, pitting edema, warmth, dilated superficial veins, erythema
What should you look for in a DVT exam? (5)
- thigh swelling 2. asymmetric calf swelling 3. superficial venous dilation 4. asymmetric skin warmth 5. Homan’s sign
What is Well’s decision making tool for DVT?
Assign one point for each clinical characteristic. Subtract 2 points if there’s an alternative diagnosis that is as likely.
What score (using Wells decision tool) indicates likely DVT?
> 2
Potential complications of DVT? (3)
- chronic venous insufficiency 2. recurrence of DVT 3. pulmonary embolism
What is the second most common cause of sudden, unexpected natural death at any age?
pulmonary embolism
Classic triad of S/Sx of pulmonary embolism?
- hemoptysis 2. dyspnea 3. chest pain
What percentage of PE pts show the triad of symptoms?
20%
Possible DVT differentials? (3)
- gastrocnemius hematoma 2. acute cellulitis 3. Baker’s cyst
What are two classic but unreliable exam procedures for DVT?
Mose’s sign, Homan’s sign
