PAD #2 Flashcards
What is an abnormal ABI?
<0.9
What does an immediate occlusion of bloddflow feel like?
No pulses
immediate pain
like putting a rubber band around your finger
Essentials of diagnosis for an acute arterial occlusion of a limb?
Sudden pain in limb + absent limb pulses
Some degree of neurologic dysfunction with numbness, weakness, or complete paralysis
Loss of light touch sensation requires revascularization within 3 hours to save limb
Window of revascularization
3-6 hours
greater than that = more likely to lose a limb
Difference between a thrombus and an embolus
Result of THROMBUS or EMBOLUS
Thrombus - stable atheroma with fibrous cap suffers plaque rupture leading to thrombus development and acute occlusion
Patient typically has hx of intermittent claudication
Presentation may not be as dramatic if h/o chronic PAD due to development of collaterals
Embolus - large emboli most commonly come from the heart
Afib is most common cause
Atherosclerosis of larger vessels may suffer plaque rupture, creating a thrombus, which can break off and travel to smaller vessels (embolus)
Atrial myxoma
tumor in the heart (more on this later)
What are the 6 P’s pf an acute occlusion
Pallor
Pain
Pulseless
Paralysis (late stage, but need immediate)
Polar / Poikilothermia (white patchiness of tissue)
Paresthesias
can happen as quick as 1 hour
How do you diagnose acute occlusion
Typically clinical
Can do a doppler
DO NOT waste time for CTA or MRA scan
TIME IS TISSUE
you may also consider
EKG
CBC PT/INR, PTT (for surgery prep)
Echo (LATER) if patient has no other risk factors
BMP, ABG
What is a bubble study
Echo
Blood flow
Check for Patent foramen ovale
(hole is between the RV and LV)
What is CRUCIAL for treating acute occlusion?
IMMEDIATE revascularization within 3-6 hours
IV heparin bolus then continuous and then revasculartization in that order (surgery includes endovascular or open-surgical)
Once stable, what do we do for acute peripheral thrombus?
source must be determined → thrombus vs embolus
If due to PAD thrombus - treat as you do other PAD patients
If due to embolus, must determine the source and treat underlying cause
Most require warfarin (Coumadin) for at least 3 months, or longer, with goal of INR of 2.0 to 3.0
Why is acute more likely to cause amputation than chronic?
Chronic has time to develop collateral bloodflow
A 75-year-old man presented to the emergency department with a 4-week history of progressive right foot pain that occurred at rest. He also had calf muscle pain that worsened when he ambulated. His medical history was significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient reported no significant surgeries in the past. He was a former smoker, who stopped smoking 5 years ago; he smoked 1 pack of cigarettes per day for 50 years before stopping. He denied use of alcohol or any other recreational drugs. Medications were low-dose aspirin, metformin, amlodipine, lisinopril, and rosuvastatin.
RED flags of this patient
On physical examination, vital signs were within normal limits. The right foot was cold. There was a shallow 3.5-cm × 2.8-cm ulceration on the medial aspect of the right first metatarsal. Pedal pulses were diminished on the left and absent on the right. Right foot sensations and muscle strength were intact. The ankle-brachial index (ABI) was calculated as 0.65 on the left and unobtainable on the right.
How would you manage this case?
Tissue damage at rest
every risk factor of PAD
older gentlemen
Manage:
He has an acute peripheral artery disease
Bolus of heparin
Vascular surgery on board
severe occlusion for ABI is?
<0.4
What is an aneurysm
ballooned vessel
What is an AAA
abdominal aortic aneurysm
What are the 4 essential of diagnose of AAA
- Most AAAs are asymptomatic until rupture
- 80% measuring 5 cm are palpable; threshold for treatment is 5.5 cm
- Back or abdominal pain with aneurysmal tenderness may precede rupture
- Rupture is catastrophic: excruciating abdominal pain that radiates to the back; hypotension (BP tanks because the vessel is messed up like crazy)
When is a abdominal aorta considered AAA?
> 3 cm
rare to rupture > 5 cm
Where are most AAA?
Aneurysms usually involve the aortic bifurcation and often involve the common iliac arteries
What is a fusiform AAA
A lot of false lumen that gets stuck and sticky
What is a Saccular AAA
also false lumen that is clotting
Presentation of AAA
Most are asymptomatic, but may have mid-abdomen and often radiating to the lower back
Symptoms of AAA
Aneurysmal expansion may cause pain that is mild to severe, located over the mid-abdomen, and often radiating to the lower back
May be constant or intermittent
Exacerbated by even gentle pressure on the aneurysm sack
Most have thick layer of thrombus lining aneurysmal sac
Distal embolization of thrombus is rare
What is an abnormal CT in AAA?
AA very close to the thoracic wall
Presentation of AAA rupture
The sudden escape of blood into the retroperitoneal space causes severe pain, a palpable abdominal mass, and hypotension.
Free rupture into the peritoneal cavity is lethal
Diagnostics of AAA
would only be performed in patients undergoing surgical repair
CBC, BMP, PT/INR, PTT
Abdominal ultrasonography is the diagnostic study of choice for initial screening for the presence of an aneurysm
CT scans provide a more reliable assessment of aneurysm diameter
Done when the aneurysm nears the diameter threshold (5.5 cm) for treatment
Contrast-enhanced CT scans show the arteries above and below the aneurysm, which is essential for surgical planning
When do you order a CTA with contrast for a AAA
Once it is 5 cm or so
refer to vascular surgery at 4.5-5.4
If you are. negative, do you do an AAA again?
No, it is unlikely they will develop one and also it will be unlikely that they will be able to survive surgery
who do you screen for AAA
One-time screening ultrasound (US) for men 65-75 y/o who have ever smoked
Could also consider screening men 65-75 who have never smoked but with considerable risk factors and family history (C)
If you find an aneurusym, what is the continued screening
Continue to screen by US depending on size
3.0 - 3.4 cm : every 2 years
3.5 - 4.4 cm: every 12 months
4.5 - 5.4 cm: every 6 months (vascular surgery referral)
Open repair vs endovascular repair
Open Repair
Excellent long-term results
Higher complication rates
1 - 5% mortality
Up to 10% risk of post-op MI (break of thrombus)
Long recovery
Endovascular Repair
Decreased 30 day mortality (0.5 - 2%)
Decreased perioperative systemic complications
There is an increased need for secondary procedures due to leaks (up to 10% of patients per year)
Prognosis of AAA after surgery
60% of AAA are alive after 5 years
MI is leading cause of death
essential of diagnose of thoracic aortic aneurysm
Widened mediastinum on chest radiograph
With rupture, sudden onset chest pain radiating to the back
MCC of atherosclerosis
atherosclerosis
What are some disorders that can lead to Thoracic Aneurysm?
Disorders of connective tissue (Ehlers-Danlos and Marfan syndromes) are rare causes but are important to note
Presentation of thoracic aneurysm
Most thoracic aneurysms are asymptomatic
Symptoms depend largely on the size and position of the aneurysm
Substernal back or neck pain
Pressure on the trachea, esophagus, or superior vena cava can result in dyspnea, stridor, or brassy cough; dysphagia; and edema in the neck and arms as well as distended neck veins
Stretching of the left recurrent laryngeal nerve causes hoarseness
With aneurysms of the ascending aorta, aortic regurgitation may be present due to dilation of the aortic valve annulus.
CXR of thoracic aneurysm
Widened mediastinum without cardiomegaly
What is an MRA used for?
Can help exclude conditions that mimic aneurysms (neoplasms, substernal goiter)
What does a cardiac cath and echo used for for thoracic aneurysm
May be needed to determine relationship of the coronary vessels aneurysm of the ascending aorta, as well as look at aortic valve (bicuspid AV or for aortic regurgitation)
How is a patient determined if they should have surgical intervention?
location of dilation
rate of growth
associated symptoms
overall patient condition
When should thoracic aneurysm be used for surgical repair?
Aneurysms measuring 5.5-6 cm or larger should be considered for repair
What are the two different repairs for thoracic aneurysm and when are they indicated?
Aneurysms of the descending thoracic aorta are treated routinely by endovascular grafting
Aneurysms that involve the proximal aortic arch or ascending aorta are more complicated¹
Most important thing to do for thoracic aneurysm management?
Manage BP
what is an aortic disection
tear in the intima and hthn the inner layer gets ripped away from the aorta, leads to a thinner outer layer
What is the presentation of aortic dissection
Partial rupture leads to HTN (BP rises because the brain is not getting enough blood, and this HTN leads to higher risk of rupture)
Pulse discrepancy because the blood leaves the aorta to go to the upper extremeties before the lower extremeties
Acute aortic regurg
Type A aortic dissection
Type A dissection - involves the arch proximal to the left subclavian artery
Type B aortic disseaction
Type B dissection - occurs in the proximal descending thoracic aorta typically just beyond the left subclavian artery
Worse type of aneurysm
Type A
What is the demographic of aortic dissection
More common in men over 50
The incidence in the US is 0.2 to 0.8 cases per 100,000 people yearly, resulting in about 2000 new cases each year.
HTN
Hyperlipidemia
Surgery
Aging
trauma
Aortic valve defect
pre-existing aneurysm
coarc of aorta
preggo (elevated BP while preggo)
Preentation of aortic dissection
Severe and persistent
Sudden onset
Radiates to the back and possibly the neck
The patient is usually hypertensive
Signs and symptoms of disrupted perfusion to vital organs
Syncope, hemiplegia, or paralysis of the lower extremities may occur
Intestinal ischemia
Renal insufficiency
Peripheral pulses may be diminished or unequal.
A diastolic murmur (Blood falls back the to aortic valve), may develop as a result of a dissection in the ascending aorta close to the aortic valve, causing valvular regurgitation, heart failure, and cardiac tamponade
Diagnostic of aortic dissection
EKG commonly reveals LVH (gets stuck in the tear)
Chest x-ray may show widened mediastinum
A multiplanar CT scan chest and abdomen with contrast is the immediate diagnostic imaging modality of choice
Must have a low threshold for obtaining a CT scan in any hypertensive patient with chest pain and equivocal findings on ECG
TEE is excellent test as well, but typically takes longer to obtain
Diagnostic imaging of choice for aortic dissection
CT w/ contrast because it allows you to plan surgery
with TEE you need to be sedated, probed, takes longer (time is tissue)
What is important to aggressively control
BP
need to reduce to 100-120 before diagnostics
reduces the burden of the dissection
First line therapy of aortic dissectino
labetolol
esmolol
If first line for aortic dissection is not at 100/120 systolic, what do you add
CCB
Nitroprusside
Pain for aortic dissection
Morphine
Type A surgical intervention
NEEDS surgery
Type B surgical intervention
May or may not need surgery
What is berger’s disease
Typical in male cigarette smokers
Involves distal extremities causing severe ischemia, progressing to tissue loss
Thrombosis of superficial veins is possible
Smoking cessation is ESSENTIAL!
s/s of Buergers disease
Segmental, inflammatory, thrombotic processes that occur in the small distal arteries and occasionally veins of extremities - NOT ATHEROSCLEROSIS
Cause is unknown
Pathology examination reveals arteritis
MC involevment of bergers disease
toes/feet FIRST
then
plantar and digital vessels
What is pain of buergers
Most patients (70-80%) present with distal ischemic rest pain or ischemic ulcerations on the toes, feet, or fingers
Claudication is less common
Superficial thrombophlebitis may occur
Progression of the disease may lead to involvement of more proximal arteries, but involvement of large arteries is unusual
Can have intermittent episodes
What is the testing done for buergers disease
CBC, CMP, Coagulation studies
TEE
Rheumatologic testing (DDx includes other vasculitides)
Arterial duplex
CTA or MRA
What is diagnostic for Buerger’s disease on MRA or CTA
Corkscrewing of vessels in males that is less than 40 that smokes
What is the only treatment option of Buerger’s diseaes
Smoking cessation
Hard to treat with surgery because of how small the vessels are
rest is symptomatic
NSAIDs
Opiods
Complication of Bergers
ulcerations, gangrene, infection
Determining need for amputation:
Patients who stop tobacco use can prevent amputation
For patients who continue using tobacco, there is an 8-year amputation rate of approximately 40%
Uncommon cause of death
