LE Arterial Complex Pathology

Question 1

what are 2 other names for Buerger’s Dx?

What is it?

what is it associated w/?

are bypasses effective?

Answer 1

Thromboangitis obliterans (TAO)

Inflammation of medium to small vessels in LE
Thrombosis secondary to inflammation

High risk of limb loss
90% men

Associated with heavy smoking
Bypasses are not effective treatment b/c small vessel disease

Question 2

a _______ is the Dilation of all layers of vessel wall

what types are there?

what’s the deal with its size?

Answer 2

aneurysm

Fusiform
Saccular
dissecting - only from ao to iliacs, doesn’t get down into LE too much

LE arterial >1.5 cm. if it increases in size 50% + it is an aneurysm. normal size of common iliac is 1cm hence 1.5cm is aneurysmal

follow into both iliacs and document both sides

Question 3

If the 2D gain is _______, you may
Miss the aneurysm and see just true lumen with color

Answer 3

too low

Question 4

what is this?

Answer 4

Aneurysm with Graft

Put graft around pop aneurysm.
Check size of aneurysm on f/u
Check flow in graft

Question 5

what type of imaging is this ofot he pop artery? is anythig going on?

Answer 5

Arteriogram:

Note a small focal aneurysmal dilatation of the popliteal artery.

The rest of the arterial tree appears to be normal without wall irregularity

Question 6

what are some characteristics of a psuedoaneurysm?

what is it secondary to?

Answer 6

Pulsating hematoma, hole in the vessel
No true walls
Flow in and out of vessel via same hole
Spectral to and fro flow
Color Ying Yang sign
Swirling within PA
Out in systole, back in diastole

Secondary to needle stick (most common), surgery (graft) or infection

Question 7

what do you need to find in a peudoan?

what types of treatment are available?

where should the color scale be?

Answer 7

Find the neck or necks
Assess width

Treatments
Compression
Thrombin injection
Surgical repair

Lower color scale to see ying-yang
flow, relatively slow swirl

Question 8

what procedure do you

Find neck with US
Compress with TD until flow stops in PA, should still have flow in artery
Hold 10-15 min, repeat up to 4-6X
Risk DVT
Some labs put PPG on foot to document continued flow to foot

Answer 8

Pseudoaneurysm Compression

Question 9

what steps must you take w/ PA Thrombin Injection? what is it used for?

Answer 9

Find neck with US

Guide injection where flows AWAY from vessel

Image thrombosis of PA

Risk are thrombosis of artery

clot pseudoa

Question 10

what type of flow would you expect to see prox and distal artery and vein of an AV fistula?

what are these often secondary to?

Answer 10

Artery prox low resistance
Artery distal low amplitude and high resistance
Vein proximal is pulsatile
Decrease in pressure distal

Secondary to needle stick, surgery, infection or in situ graft.

Question 11

what is AKA Compartment Syndrome

Restricted flow in pop only with vigorous exercise
No vascular stenosis
Compression/
impingement of artery by something

Answer 11

The Popliteal Artery Entrapment Syndrome (PAES)

Question 12

PAES Entras the popliteal artery by

medial head of the _______ (most common) – popliteal diviates medially

rarely by the deeper popliteus muscle

May be induced by______

Answer 12

gastrocnemius

repetitive trauma or acute trauma with secondary fibrosis

Question 13

what symptoms are associated w/ PAES?

Answer 13

Calf pain with exercise

Other pathology with these symptoms:
Atherosclerosis (but if patient is young, athletic, etc. this doesn’t fit)
Muscle injury
Shin splints
Compartment syndrome

Question 14

____ is the loss of pedal pulses when ankle is actively or passively dorsiflexed with the knee extended.

and

the Decrease/loss of flow documented with duplex scan with ankle flexsion.

what are the pitfals of this?

Answer 14

PAES or entrapment

Pitfalls: many normal subjects block their popliteal arteries with active ankle flexion (6).

Arteriography shows a characteristic appearance usually with medial deviation of the proximal popliteal artery and either post-stenotic dilatation or segmental occlusion of the mid-popliteal artery.

Question 15

what is this?

Answer 15

Arteriogram in a patient with short segmental occlusion of the right popliteal artery due to entrapment.

Note the smooth appearance of the proximal and distal arteries.

Question 16

_______ is AKA pseudo compartment syndrome

what is it?

whoe does it affect?

Answer 16

Cystic Adventitial Disease

Intermittent claudication of calf

Male dominant 5:1, 40-50 y/o, athletic and non-athletic
Incidence is 1:1200 patients with claudication

Mucinous cysts of adventitial tissue which impede flow with exercise

Question 17

____ is Sonographically
Hypoechoic cysts in vessel wall
Narrowed lumen best demonstrated with color Doppler
US useful in differentiating cystic adventitial disease from atherosclerotic disease.

or MRI
Cystic appear as high signal fluid
Lumen narrowed on MRA

Answer 17

Cystic Adventitial Disease

Question 18

what treatements are available for Cystic Adventitial Disease

Answer 18

Surgical “de-roofing” to avoid dissection and thrombosis (cut into vessel through the outer layer to release the pressure created by the cyst opening up the lumen)

Cyst aspiration may be attempted

Bypass may be needed in severe cases

Question 19

_______ Rarely affects the external iliac artery

Present with claudication, embolism causing `blue toe syndrome’, or acute ischemia from dissection

More common in renal arteries, CV system

Duplex shows multiple areas of narrowing

Arteriography focal stenoses and intervening mural dilatations, “string of pearls”

Answer 19

Fibromuscular dysplasia

*more common in females

-muscular wall of vessel hypertrophies (becomes thickened) narrowing the lumen

Question 20

what is this? how can you tell?

Answer 20

Fibromuscular dysplasia
This is an example of FMD in the CV system
It would look similar in the LE arterial system

• string of pearls