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Cardiovascular > PAD pt 2 > Flashcards

PAD pt 2 Flashcards

1
Q

Acute Occlusion is a result of?

A

THROMBUS or EMBOLUS

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2
Q

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

A

thombus

Pt has hx of intermittent claudication
Presentation may not be as dramatic if h/o chronic PAD due to development of collaterals

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3
Q

large emboli MC come from where?

A

the heart

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4
Q

MCC of embolus

A

Afib
Atherosclerosis of larger vessels may suffer plaque rupture, creating a thrombus, which can break off and travel to smaller vessels (embolus)

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5
Q

presentation of acute occlusion

A

6 P’s:
* Pallor
* Pain
* Pulseless
* Paralysis
* Polar / Poikilothermia
* Paresthesias

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6
Q

diagnostics for acute occlusion

A
  1. CLINICAL dx
  2. Doppler - little/no flow in distal vessels
  3. AVOID: Acute imaging (CTA or MRA) if light touch sensation compromised
    - Causes a delay in therapy
    - Often used to examine extent of arterial occlusion in OR
  4. EKG - determine if pt is in Afib
  5. CBC, PT/INR, PTT - pre-op
  6. Echo - done LATER if embolic source is suspected
    - TEE with bubble study preferred
  7. BMP, ABG - met acidosis, hyperkalemia, rhabdomyolysis, AKI
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7
Q

management for acute occlusion

A
  1. Immediate revascularization for all sx acute arterial thrombosis
    - within 3 hrs of sx
  2. Emergent vascular surgery consult is VITAL!
    - IV Heparin bolus ASAP and continuous infusion
  3. Endovascular or open-surgical approaches are taken to revascularize the limb
  4. Once stable, source must be determined → thrombus vs embolus
    - If thrombus - treat as you do other PAD pts
    - If embolus - determine source and tx underlying - Most require warfarin x +3 mo, goal of INR of 2.0 to 3.0
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8
Q

causes of AAA

A
  1. Dilatation of infrarenal aorta is a nml part of aging
  2. aorta normally measures 2 cm
    - AAA = > 3 cm
    - Rare to rupture under 5 cm
  3. MC men over 55 years of age
  4. MC below renal arteries
    - Aneurysms usually involve aortic bifurcation and often involve common iliac arteries
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9
Q

RF for AAA

A
  • Male
  • Smoking history
  • Family History
  • Increasing Age
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10
Q

classification of AAA

A
  • Fusiform: circumferential expansion of the aorta
  • Saccular: outpouching of a segment of the aorta
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11
Q

presentation of AAA

A
  1. Asx - Most are incidental findings on imaging
  2. Symptomatic → PAIN!
    - mild-severe, located over the mid-abd, and radiating to lower back
    - May be constant or intermittent
    - Exacerbated by even gentle pressure on aneurysm sack
    - Most have thick layer of thrombus lining aneurysmal sac - Distal embolization of thrombus is rare
  3. Symptomatic → RUPTURE!
    - severe pain, palpable abd mass, and hypotension.
    - Free rupture into peritoneal cavity is lethal
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12
Q

diagnostics for AAA

A
  1. Labs - only if undergoing surgical repair
    - CBC, BMP, PT/INR, PTT
  2. Abd US - initial screening for presence of aneurysm
  3. CT - more reliable assessment of diameter
    - Done when aneurysm nears 5.5 cm diameter threshold for tx
    - Contrast-enhanced CT show arteries above and below aneurysm, which is essential for surgical planning
  4. Once aneurysm is identified, routine f/u + US will determine size and growth rate
    - Frequency of imaging depends on size of aneurysm
    - aneurysm at 5 cm, = CTA + contrast
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13
Q

Screening for AAA

A
  1. USPSTF Recommendations (B):
    - One-time screening 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)
  2. What if you find an aneurysm? - 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 = Should be referred to Vascular Surgery at this point
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14
Q

management for AAA

A
  1. elective repair
    - Indicated for aneurysms ≥ 5.5 cm OR rapid expansion (>0.5 cm growth in 6 mo)
    - sx (pain, tenderness) may precipitate urgent surgical intervention regardless of diameter
  2. rupture - EMERGENT ENDOVASCULAR REPAIR
    - Lethal if not repaired
  3. Aortic Inflammation/Inflammatory Aneurysm
    - tx cause (vasculitis, infection, retroperitoneal fibrosis)
    - Surgical indications: aneurysms ≥5.5 cm, compression of retroperitoneal structures (ureter), or pain w/ palpation
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15
Q

2 AAA surgical repair mechanisms

A
  1. Open Repair
    - Excellent long-term results
    - Higher complication rates
    - 1-5% mortality
    Up to 10% risk of post-op MI
    - Long recovery
  2. Endovascular Repair
    - Decreased 30 day mortality (0.5 - 2%)
    - Decreased perioperative systemic complications
    - increased need for secondary procedures d/t leaks (up to 10% of pts per year)
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16
Q

prognosis of AAA

A
  1. survived surgical repair - 60% are alive at 5 yrs
    - Long-term survival (≥ 5 years) is equivalent for open and endovascular repair
  2. Untreated aneurysm mortality rate varies with aneurysm diameter
    - > 6 cm = 12% annual risk of rupture
    - > 7 cm = 25% annual risk of rupture
  3. aortic aneurysm >5.5 cm have 3x high risk of dying from rupture > surgical resection
17
Q

MCC of death from AAA surgical repair

A

MI is the leading cause of death

18
Q

causes of Thoracic Aneurysm

A
  1. MCC by atherosclerosis
  2. Disorders of connective tissue (Ehlers-Danlos and Marfan syndromes) are rare causes but are important to note
  3. Bicuspid aortic valve disease is also a rare cause
  4. < 10% of aortic aneurysms occur in the thoracic aorta
19
Q

presentation of thoracic aneurysm

A
  1. Most asx
  2. sx depend on size & position of 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 L recurrent laryngeal nerve = hoarseness
    - With aneurysms of the ascending aorta, aortic regurgitation may be present due to dilation of the aortic valve annulus.

Rupture is catastrophic - bleeding is rarely contained, allowing no time for emergent repair

20
Q

diagnostics for thoracic aneurysms

A
  1. CXR - widened mediastinum
    - Can also show a calcified outline
  2. CT w/ contrast (1st line) - demonstrate anatomy and size of aneurysm
  3. MRA - r/o conditions (neoplasms, substernal goiter)
  4. Cardiac cath & echo - determine relationship of coronary vessels aneurysm of ascending aorta, as well as look at aortic valve (bicuspid AV or for aortic regurgitation)
21
Q

management for thoracic aneurysm

A
  1. Surgical Repair
    - Aneurysms measuring >5.5-6 cm
  • Aneurysms of descending thoracic aorta - endovascular grafting
  • involvement of proximal aortic arch or ascending aorta - more complicated
22
Q

indications for thoracic aneurysm repair depend on:

A

location of dilation
rate of growth
associated symptoms
overall patient condition

23
Q

screening for thoracic aneurysm

A
  1. No current guidelines on screening for thoracic aortic aneurysm
  2. Referral to CT surgeon or vascular surgeon at time of dx
    - Monitor size with TTE / CT chest x 6-24 mo depending on size and rate of growth
  3. Controlling RF and BP is important to lower risk of growth and rupture
24
Q

occurs when a spontaneous intimal tear develops and blood dissects into the media of the aorta

A

Aortic dissection

25
Q

how are Aortic dissections classified

A

by entry point and distal extent

  • Type A dissection - involves arch proximal to L subclavian artery
  • Type B dissection- occurs in proximal descending thoracic aorta typically just beyond L subclavian artery
26
Q

aortic dissection is MC in who?

A

men >50

27
Q

presentation of aortic dissection

A
  1. Chest pain
    - Severe and persistent, Sudden onset
    - Radiates to back and possibly neck
  2. hypertensive
  3. disrupted perfusion
    - Syncope, hemiplegia, or paralysis of the lower extremities may occur
    - Intestinal ischemia
    - Renal insufficiency
    - Peripheral pulses may be diminished or unequal.
  4. diastolic murmur - a dissection in ascending aorta close to AV = valvular regurg, HF, and cardiac tamponade
28
Q

diagnostics of aortic dissection

A
  1. EKG - LVH
  2. CXR - widened mediastinum
  3. A multiplanar CT scan chest & abdomen w/ contrast - immediate diagnostic imaging modality of choice
    - Must have low threshold for obtaining a CT scan in any HTN pt w/ CP and equivocal findings on ECG
  4. TEE - excellent, typically takes longer to obtain
29
Q

management for aortic dissection

A
  1. BP control
    - Aggressive measures before dx studies have been completed
    - Lower SBP to 100–120 mmHg and lower pulse pressure
    - Labetalol → alpha- and beta-blocker; lowers pulse pressure and achieves rapid blood pressure control
    - Alt: esmolol
    - Add IV CCBs (nicardipine) or nitroprusside if BP not to goal
  2. Pain: Morphine
  3. Surgical Intervention
    - Required for all type A dissections
    - Type B dissections + signs of malperfusion of target tissues too
30
Q

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

A

Buergers

31
Q

Buergers MC starts where?

A

Starts with toes/feet and with disease progression
MC plantar and digital vessels of foot/leg
Can see hand/finger involvement in advances stages

32
Q

Buergers is MC in who?

A

male smokers <40 y/o

33
Q

presentation of Beurgers

A
  1. MC distal ischemic rest pain or ischemic ulcerations on toes, feet, or fingers
    - Claudication is less common
  2. Superficial thrombophlebitis may occur
  3. Progression of the disease may lead to involvement of more proximal arteries, but involvement of large arteries is unusual
    - Can have intermittent episodes
34
Q

diagnostics for Buergers

A

Most to r/o other thromboembolic sources for the distal ischemia
1. CBC, CMP, Coagulation studies
1. TEE
1. Rheumatologic testing (DDx includes other vasculitides)

Arterial duplex
CTA or MRA - corkscrew!

35
Q

management for Buergers

A
  1. tobacco cessation is only effective tx!
  2. Revascularization of occluded vessels is rarely an option as there are no good distal targets
    - Amputation required for ischemic areas
  3. Pain - NSAIDs/opioids
  4. All other forms of pharm have been generally ineffective - Steroids, calcium-channel blockers, vasodilators, antiplatelet drugs, and anticoagulants
36
Q

prognosis/complications of Buergers

A
  1. Complications: ulcerations, gangrene, infection
  2. Determining need for amputation:
    - pts who stop tobacco use can prevent amputation
    - For pts who continue using tobacco, there is an 8-yr amputation rate of approximately 40%
  3. Uncommon cause of death

Cardiovascular (24 decks)

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