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Cardio > PAD II - Exam 3 > Flashcards

PAD II - Exam 3 Flashcards

1
Q

What are the 3 essentials of diagnosis for acute arterial occlusion of a limb?

A
  1. Sudden pain in limb + absent limb pulses
  2. Some degree of neurologic dysfunction with numbness, weakness, or complete paralysis
  3. Loss of light touch sensation requires revascularization within 3 hours to save limb
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2
Q

Acute Arterial Occlusion of a Limb a result of ____ and _____.

A

thrombus or embolus

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3
Q

Acute Arterial Occlusion of a Limb due to thrombus happened because of ???? Pts typically has hx of _________.

A

stable atheroma with fibrous cap suffers plaque rupture leading to thrombus development and acute occlusion

intermittent claudication

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4
Q

Acute Arterial Occlusion of a Limb due to a embolus MC come from the ______. ______ is the MC.

A

heart

Afib is the MC

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5
Q

What is the main difference between thrombus and embolus?

A

thrombus is a stationary blood clot, while an embolus is a blood clot that moves through the bloodstream

Thrombus: A blood clot that forms in a vein, artery, or the heart.

Embolus: A blood clot or other substance that breaks off from a thrombus and travels through the bloodstream until it reaches a vessel that’s too small to pass through

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6
Q

**What are the 6 P’s of Acute Arterial Occlusion of Limb?

A

Pallor
Pain
Pulseless
Paralysis
Polar / Poikilothermia
Paresthesias

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7
Q

Acute Arterial Occlusion of Limb dx is ________. What will a doppler show? What needs to be avoided if ______?

A

clinical diagnosis!! do not want to delay revascularization

Doppler demonstrates little to no flow in distal vessels

Acute imaging, such as CTA or MRA, should be avoided if light touch sensation compromised

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8
Q

in Acute Arterial Occlusion of Limb _____ is done later if embolic source is suspected. What kind specifically?

A

echo

TEE with bubble study

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9
Q

**What 7 criteria are used to classify acute arterial occlusion of limb?

A

pain
cap refill
motor deficit
sensory deficit
arterial doppler
venous doppler
recommended treatment

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10
Q

What is the management of Acute Arterial Occlusion of Limb? What specific timeframe?

A

Revascularization should be accomplished within 3 hours of symptoms

  1. emergent vascular sx consult
  2. IV heparin bolus and continuous infusion
  3. endovascular or open sx to revascularize the limb
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11
Q

What do you do in acute arterial occlusion of limb once the pt is stable?

A

find the source

if PAD thrombus tx PAD: ASA/plavix, statin, risk factor modification

embolus: determine the source and tx
Most require warfarin (Coumadin) for at least 3 months, or longer, with goal of INR of 2.0 to 3.0
May add holter monitor at discharge to monitor for underlying afib

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12
Q

______ is the difference between adbominal and thoracic aortic aneurysms

A

diaphragm

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13
Q

What are the 4 essentials of AAA diagnosis?

A
  1. Most AAAs are asymptomatic until rupture
  2. 80% measuring 5 cm are palpable; threshold for treatment is 5.5 cm
  3. Back or abdominal pain with aneurysmal tenderness may precede rupture
  4. Rupture is catastrophic: excruciating abdominal pain that radiates to the back; hypotension
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14
Q

_____ size is the threshold for AAA tx. 80% of _____ are palpable

A

5.5cm must tx

5cm are palpable

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15
Q

What is the size of a normal aorta? When is it considered an AAA? 90% of AAA develop ________.

A

2cm

Considered a AAA when > 3 cm

below the renal arteries

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16
Q

What are the risk factors for AAA?

A

Male gender
Smoking hx
Family hx of AAA
Increasing age

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17
Q

**What are the 3 classifications of AAA? Give a brief description of each

A

Fusiform: Circumfirential dilation of the aorta

Saccular: Outpouching of a segment of the aorta

Location relative to renal arteries

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18
Q

**Name this AAA

A

suprarenal

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19
Q

**Name this AAA

A

pararenal

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20
Q

**Name this artery

A

juxtarenal AAA

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21
Q

**Name this AAA

A

infrarenal

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22
Q

most AAA are discovered as _____ on imaging. If symptomatic, what will the pt complain of?

A

incidental findings

PAIN in the mid-abdomen that often radiates to the lower back

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23
Q

What makes a symptomatic AAA worse? Is the pain constant?

A

any sort of pressure to the aneurysm even gentle pressure

may be constant or intermittent

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24
Q

What will an AAA rupture present like? Is it lethal?

A

severe and intense pain, palpable mass and hypotension

Free rupture into the peritoneal cavity is lethal!

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25
Q

What are the AAA rupture risk based on the size?

A
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26
Q

_______ is the diagnostic study of choice for initial screening for the presence of an aneurysm. _______ provide a more reliable assessment of aneurysm diameter. When would you do one?

A

Abdominal ultrasonography

CT scan: Done when the aneurysm nears the diameter threshold (5.5 cm) for treatment. Want contrast and look at the arteries above and below the aneurysm

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27
Q

Once the AAA reaches _____, need to start CT scans

A

5cm then CT scans

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28
Q

What are the USPSTF recommendation for AAA screening?

A

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)

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29
Q

**What are the monitoring requirements for AAA? Give the specific size of the AAA and the specific test

A
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30
Q

**What is the growth rate of AAA that warrantes concern?

A

If we see rapid growth (>0.5cm in 6 mos), we can monitor more frequently/repair!

31
Q

**_______ is recommended after 5cm. Repair is warranted for all aneurysms ____ regardless of symptoms. Once they get ____ in size, vascular sx needs to be involved

A

CTA with contrast

> 5.5cm

4.5cm then vascular

32
Q

When is an elective repair indicated in AAA?

A

Indicated for aneurysms ≥5.5 cm OR those with rapid expansion (>0.5 cm growth in 6 months)

Symptoms (pain, tenderness) may precipitate urgent surgical intervention regardless of diameter

33
Q

**If an AAA were to rupture spontaneously, ____ of pts die prior to reaching the hospital. What is the tx? Of those who reach tx, ____ of those patients survive

A

½

endovascular repair and only 1/2 of those patients survive surgery

34
Q

When is AAA sx indicated?

A

Surgical indications: aneurysms ≥5.5 cm, compression of retroperitoneal structures (ureter), or pain with palpation

35
Q

**What are the pros and cons of open AAA repair and endovascular repair?

A

Long-term survival (≥ 5 years) is equivalent for open and endovascular repair

36
Q

For those who survive surgical repair, approximately ____ of AAA patient’s are alive at 5 years. Generally, patients with an an aortic aneurysm ____ have a ____high risk of dying from rupture than of surgical resection

A

60%

> 5.5 cm

3x

37
Q

______ is the leading cause of death in pt who survival AAA repair

A

MI

38
Q

What are the 2 essentials of diagnosis for thoracic AAA?

A
  1. Widened mediastinum on chest radiograph
  2. With rupture, sudden onset chest pain radiating to the back
39
Q

What is the most likely cause of thoracic aneurysms? What are 2 associated connective tissue disorders? _____ is also associated

A

atherosclerosis

Ehlers-Danlos and Marfan syndromes: both connective tissue disorders

Bicuspid aortic valve disease

40
Q

What percent of AA occur in the thoracic cavity? must be above the _____

A

less than 10%

diaphragm

41
Q

Most thoracic aneurysms are ______. But classic can present like _______

A

asymptomatic

Substernal back or neck pain - most classic

42
Q

If the thoracic aortic aneurysm is putting pressure on the trachea, what will it present like? Stretching of the ______ nerve causes ______

A

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

left recurrent laryngeal

43
Q

How will a rupture of the Thoracic Aortic Aneurysm present?

A

Will present with sudden onset CP radiating to back

usually catastrophic because the bleeding is rarely contained

44
Q

**______ is included in the thoracic aortic aneursym work-up. What will it show? **_____ is modality of choice. What will it show?

A

Chest x-ray will show widened mediastinum

CT scan with contrast: demonstrate the anatomy and size of the aneurysm

45
Q

______ can also be useful in TAA to help exclude conditions that may mimic aneurysms

A

MRA

46
Q

_____ and ____ may be needed in TAA to help determine the relationship of the coronary vessel aneurysm of the ascending aorta. Alos looks at the aortic valve to look for regurg

A

Cardiac catheterization and echocardiography

47
Q

What is the tx for TAA? What size?

A

Surgical Repair-> CT surgery for these

Aneurysms measuring 5.5-6 cm or larger

48
Q

Aneurysms of the ______ are treated routinely by endovascular grafting versus Aneurysms that involve the _____ or _____ are more complicated

A

descending thoracic aorta

proximal aortic arch or ascending aorta

49
Q

What are the pharm managements for TAA? What medication class needs to be avoided?

A

BP control: BB, ACE/Arbs are preferred

statins

AVOID fluoroquinoloes

50
Q

What are the screening recommendations for TAA?

A

No current guidelines on screening for thoracic aortic aneurysms

51
Q

What do you do if your find TAA on any imaging? ** What is the monitoring requirements?

A

Referral to CT surgeon or vascular surgeon at time of diagnosis, regardless of size or symptoms, is recommended

** CT sx will monitor size with transthoracic echo or CT chest every 6 to 24 months depending on size and rate of growth

52
Q

For AA monitoring is based on _______. Larger size = ______. Ascending aortic aneurysm = ______

A

location

larger size = CT

ascending aortic aneurysm= CT

53
Q

**What are the 4 essentials of diagnosis for aortic dissection?

A
  1. Sudden searing chest pain radiating to the back, abdomen, or neck in a hypertensive patient
  2. Widened mediastinum on CXR
  3. Pulse discrepancy in extremities
  4. Acute aortic regurg may develop
54
Q

**What are the 2 types of aortic dissection? Give a brief description of each

A

Type A dissection - involves the arch proximal to the LEFT subclavian artery (this is the separation point)

Type B dissection - occurs in the proximal descending thoracic aorta typically just beyond the left subclavian artery

55
Q

aortic dissections are classified by _____ and -______

A

entry point and distal extent

56
Q

Which type of aortic dissection is considered more dangerous and have concerns about ______

A

type A is more dangerous and concerned about cardiac tamponade

57
Q

What are the risk factors for aortic dissection? **What is the highlighted one?

A

Aging
Atherosclerosis
High Blood Pressure
Blunt trauma to chest wall
Aortic valve defect (AS)
Aortic Coarctation
Pre-existing aortic aneurysm
Pregnancy

58
Q

What is the presentation of an aortic dissection?

A

Severe and persistent with SUDDEN onset

Radiates to the back and possibly the neck

pt is hypertensive

s/s of disrupted perfusion to vital organs

peripheral pulses may be diminished or unequal

59
Q

A ______ may develop as a result of a aortic dissection in the ascending aorta close to the aortic valve, causing valvular regurgitation, heart failure, and tamponade

A

diastolic murmur

60
Q

What 3 diagnostic tests do you want to order if you suspect aortic dissection? What will each reveal? **What is the immediate diagnostic imaging modality of choice?

A

EKG commonly reveals LVH

Chest x-ray may show widened mediastinum

Multiplanar CT scan chest and abdomen with contrast

61
Q

a hypertensive patient with chest pain and equivocal findings on ECG, what should you IMMEDIATELY order?

A

Multiplanar CT scan chest and abdomen with contrast

62
Q

_______ should occur when aortic dissection is suspected, even BEFORE diagnostic studies have been complete

A

Lower the systolic blood pressure to 100–120 mmHg and lower pulse pressure

BB: Labetalol**
esmolol if you want a shorter 1/2 life

IV: Nicardipine (CCB) can be added if BP is not to goal

63
Q

______ is the pain control drug of choice in aortic dissection

A

morphine

64
Q

_______ is required for all _____ type dissections. What does it involve?

A

surgical intervention

all type A dissections

Involves grafting and replacing the diseased portion of the arch and brachiocephalic vessels as necessary

65
Q

type B aortic dissections _______ of target tissues require _______

A

with signs of malperfusion

urgent surgery as well

66
Q

What is the technical name for Beuger Disease? **What is the MC pt type? What is the underlying process?

A

Thromboangiitis Obliterans

younger (less than 40) male cigarette smokers

Involves distal extremities causing severe ischemia, progressing to tissue loss. Thrombosis of superficial veins is possible

67
Q

What is the etiology of Buerger’s disease? **What is important to note?

A

Segmental, inflammatory, thrombotic processes that occur in the small distal arteries and, occasionally, veins of extremities

NOT ATHEROSCLEROSIS

68
Q

Where does Buerger’s disease typically start? What are the MC vessels?

A

Starts with the toes/feet and with disease progression

MC plantar and digital vessels of foot/leg with a dusky appearance

69
Q

In Buerger’s disease, _______ is less common and _______ may occur. ______ is unusual. What is the associated timing?

A

claudication is less common

Superficial thrombophlebitis may occur (infection of the superficial vein)

involvement of the large arteries is unusual

intermittent episodes

70
Q

Why is testing done in Buerger’s disease?

A

Most testing done is to rule out other thromboembolic sources for the distal ischemia

CBC, CMP, coag studies, TEE, Rheumatic testing, arterial duplex, CTA or MRA

71
Q

What is the management for Buerger’s disease? What should you NOT do?

A

Absolute tobacco cessation is only effective treatment! NSAIDs/ opioids for pain control

all other pharm options are generally ineffective

revascularization is rarely an option because they are NOT used in distal veins

72
Q

For pts with Buerger’s disease who continue to use tobacco there is an _________.

A

8-year amputation rate of approximately 40%

73
Q
A

Cardio (20 decks)

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