PAD vasc boards ACC-SAP and Cath-SAP Flashcards
atypical claudication sx
heaviness or weakness with stairs/ ambulation (this is seen in ~30%)
definition of intermittent claudication (4 parts)
discomfort cramping or aching in calves, thighs buttox that
- comes on with exertion
- improves with rest
- reproducible
ddx (4) of acute onset leg pain
- athero/thromboemboli (AF,AAA)
- plaque ruputure
- dissection
- other embolic conditions –> infectious, metastatic
hx signaling location of PAD lesion
isolated calf? –> SFA
Buttox and calf –> aorto iliac
How do ABI
higher DP or PT over higher arm right or left
when do TBI
abi > 1.4
when do exercise
0.9 to 1.4 with sx’s
what direction is arterial flow shown in ultrasound
R to L (higher to lower)
abn u/s findings the basics (4) and examples
- easiest increased systolic velocity (ie > 125 cm/s)
- increased end diastolic velocity (ie > 40 in ICA) off baseline
- Aliasing
- smaller diameter
65% stenosis in the CIa which is a class 1 indication –> asx
statin
PAD recommendations for antiplt rx guildlines (give level of recommendations I, IIa, IIb)
1a. ASA alone or plavix alone class Ia in symptomatic pts with PAD (monotherapy)
IIa - asx patients with PAD antiplt (ASA or plavix is reasonable) < 0.9)
IIb. asx with b/l abi 0.91-0.99 uncertain benefit ot antiplatelet
statins also Ia
Note riva 2.5 bid + asa will be IIa soon likely! given compass pad
data for Ia recommendation for statins
heart protection study in lancet 2002 24% RR reduciton < 0.00001 for patients with mi, chd, pad, stroke or dm (note DM data was extremely powerful)
what was the heart protection study.
simvastatin in patients with some form of vascular dz (MI, HF, CVD, DM) and showed a 24% relative risk reduction
it was in lancet in 2002.
NOACs or coumadin in PAD?
III? what about compass? –> now showing benefit. eickelboom JW
Compass PAD –> riva 2.5 bid + asa 81with HR of 0.72 p0.005. this is going to change everything. patients with pad will be on riva +asa as a class I however there is a price of excess bleeding. This will change how we manage PAD (compass PAD lancet 2018)
compass pad
asa + riva 2.5 in secondary prevention of PAD with HR of 0.72 and p of 0.0005 vs asa alone.
what about rx to reduce claudicatoin
cilostazole (cant use with CHF) class I. pentofxifyline is class III
moa of cilosazole
grade of recommmendation
warning
who would you use it in?
phospdiaesterase III inhibitor
class I
cant use in CHF.
no one.
class I recs for sx pad (claudication)
statin asa or clopidogrel (riva may be coming) cilostazole although we dont use it structured exercise (supervised over unsupervized when availibe class Ia vs. IIa)
when is an endovascular intervention Ia?
IIa?
IIb?
Ia? lifestyle limiting aorto-iliac claudication
IIa? fempop
infrapop
class III recommendatio regarding endovascular intervention in claudicaiton
class III - endovascular procedures should not be performed in patients with pad soley to prevent progression to CLI
grade this statement “endovascualr procedures should not be performed in patients with PAD soley to prevent progression to CLI
class III harm.
surgery for claudication when class I, IIa, III (2)
I vein over prostethic dacron grafting ehn feasible
IIa. surgical procedures are reasonable as revasc option for patients with lifestyly limiting claudication with inadequate response to GDMT and technical factors suggesting advantages over endovascular procedures.
III. harm femoral tibial a. bypass with prosthetic grafts should NOT BE USED FOR CLUAIDICATION
III surgical procedures for claudication shouldbt be performed to prevent progressoin to CLI
5 year patecy for aortoilica or aortofemoral bypasses
90%
CLI endovascular rx recs if have nonhealing wounds or gangrene
what about CLI 2/2 rutherford IV (rest pain)
angiosome directed endovascualr rx in patients with CLI and nonhealing wounds/ gangrene
Class I,
IIa
IIb -
medical therpay with heparin with ALI
class I for acute limb ischemia.
ALI cathereter based thrombolysis
Ia! catheter directed throbmolysis and limb salvage.
if fempop aneursysms have a 20% incidence of also having this
20%
surgery is recommended for pop aneursysms > ___ cm ?
2 cm
5 way ddx of upper ext PAD
- atherosclerosis duh.
2 vasculitis - takayasu’s young and gca old with pmr
3 compression syndroms - arterial or venous, thoracic outlet
4 embolic
5 vasc malformaitons
for each of the follwing conditoins name the arterial/venous beds that are possibly involved
- GCA
- TA
- PAN
- KD
- BD
- GCA - thoracic aorta, abd aorta, carotids, UEs,
- TAs - throacic, abdominal, pa, carotid, ue
- PAN Mesenteric, renals
- KD - cors
- BD -Upper ext LE ext
for each vascular bed distribution name thevasculitic dz
1. Upper and LE only
2. pa, carotids, thoracic ao, abd, aor, upper ext
3. mesenteric and renal a
4. carotids thoracic ao, abd ao, UEs
.5 coronaries
- Bergers
- TA (takayasu)
- PAN
- GCA or TA (young TA old GCA) similar arteries except TA can involve pa as well.
- Kawaskai
bergers dz men or woment
men»_space;» women
bergers triad
raynauds, cluadication superfical thromboplebitis
claudication, raynauds, superfical thrombophlebitis
buergers dz
bergers upper vs lower ext
biggest risk factor
angiogram two findings
classically upper ( more common)
Heavy heavy smoking 2-3 ppd x 10 years of morec
spasm in distal ext (usual hand -> fing lost of flow and spasm with “cork screw collaterals”
buergers aka
thromboangitis obliterans
thromboangitis obliterans
buegers
angiogram of hand with corkscrew collaterals
“buergers”
when consider renal a dz? 5 times for boards
- flash
- early (< 30) or late accellerated htn (> 55 yo)
- resistant htn
- kiney size discrepancy
- azotemia with ace
kidney size discrepancy c/w ras
1.5 cm
what velocities in renal a are consistent with RAS
> 200 cm/s systolic
150 cm /s
post stenotic turbulent flow
class I rec for stenting with RAS? IIa?
class I flash edema hemodynamic signficant RAS with malignant and resistant htn or htn with unexplained small kiney, or cKD with bilateral dz /affecting solitary kindey, RAS and stable anginga.
abd pain acute onset out of proportion to exam
acute mesenteric ischemia. mortality is >50% and 30 % in venous thrombosis,
chronic mesentic ischemia
chronic post prandial d/c and wieght loss
note need 2/3 mesentic vessels and treatment is revasc.
def TIA
TIA over 3 months in TIA
< 24 hrs usually < 15 min WITHOUT EVIDICNE OF STROKE ON DWI MRI!
25% adverse vents and 10% stroke
time windown for acute stroke tpa
thrombectomy comined with thrombolystic
4.5 hrs.
ranikin scale improved for TPA+ mech thrombectomy SAVR JL NEJM 2015usual mca or ACA
now 5 studies (halperin jacc 2016)
AF is the cause of __% of cryptogenic stroke
15%
R to L on Us
caudal to cranial direction
stenosis estimates based on velocity !!
200 cm/sec -50%
250 cm/sec 70%
300 cm/ sec 80%
400 cm/sec 90%
250 cm/sec on carotid us
~70% stenosis
antithrombotic rx in carotid dz
obstructive class I-asa alone or clopidogrel alone or asa class I +diparamidole 81 +200
BUT (2013 weng in china, dapt is better after minor stroke) ? so many centers do dapt for 21 days. (not us)
lacunar strokes no role for dapt and risk is hemorrhage. I feel like we just do asa here
TIA, and carotid dz is found… how quickly do you need to decide to go aheah
within 2 weeks IIa
what is current recommendations for carotid revsac - havent been updated since the 90s
- 50% on angiogram with stroke sx or 70% on dopplar or CT CEA as long as anticipated risk of perioperative stork or mort is < 6%
CREST stupid conclusion from Brott NEJM
older pts better CEA 70-75 (well thats fucking everyone man)
one of best current roles for stenting
CAD needing bypass, stent then send for surgery
rutherford and fontaine classifications
fontaine I asx IIa mild IIb mod-severe III ischemic res p[ain IV rest pain
rutherford 0 asx 1 mild 2 mod 3 severe 4 ischemic 5 minor tissue loss 6 gangrene
Where does VTE rank in terms of CV death
3rd
CAD
CHF
VTE
First step in treatment of any pert case
start heparin, can be imitated even before confirmation of dx if clinical suspicion is high
Who should get Catheter directed thrombolysis
- intermediate risk PE with risk for clinical deterioration and without an abs ci to thrombolysis
- high risk PE
when does the PERT consensus recommend Surgical embolectomy
- high risk PE with failure of Systemic or Catheter directed lysis.
- mainly 2/2 RV thrombus in transit or thrombus in transit in a pfo
When to consider ECMO
patients with clinical deterioration with significant PE and refractory shock
PERT team 2 times of IVC filter
- cannot systemically anticoagulant
- pre CTEPH or Surgerical embolectomy
- large free floating proximal DVT is seen (although one could argue to do angiovac from above here….
PERT follow up
w/in 2 weeks post pe
PERT pager goes off major things want to assess
- hx, pe, labs, imaging BLEEDING RISK!!!!
5 abs and 5 relative CI to thrombolysis
5 abs: 1. Active bleeding 2. Any Hx of ICH 3. Stroke within 3 mo 4. suspected ao dissection 5 (3). Recent brain or spin surgery, recent head trauma, or active intracranial neoplasm, Vasc malformation, aneurysm or other structuralbrain dz
Relative CI -5
- age >75
- Wt < 60 kg
- known bleeding do
- INR > 1.7
- BP > 180 /DBP >110
- recent bleeding (non ICH within a month),
- current or recent pregnancy (w/in a week)
- remote ischemic stroke
Give pert consensus def of high risk, intermediate risk and low risk
High risk- SBP < 90 or a drop in SBP of 40 from baseline , or pressors or hemodynamic support
Intermediate risk PESI III/VIor RV dilation or dysfunction. by cta and echo, + tn, elevated NTp probrnp
intermediate high risk - RV dysfunction + tn pos,
intermediate low risk (either but not both RV dysfunction and tn elevation)
3 biomarkers should check with every PE
- Tn
- NT probnping
- lactate
-if all 3 pos there is an almost a 20% chance of mortality or hemodynamic collapse with medical rx.
When do we do catheter directed thrombolysis?
High risk or intermediate high risk (PESI III./IV, sPESI >=1, biomarker + esp if lactate too, and signs of rv strain).
VTE epi key points
1 million per year. 100,000 deaths. <10% have a genetic risk
acquired risk factors for VTE (6)
- cancer
- age related VTE
- obesity
- varicose veins
- hormone rx.
- preg
wells score helpful use?
score greater than 4 start treatment prior to scan if bleeding risk is acceptable.
unprovoked VTE how long AC
indefinite with reassessment of bleeding risk.
calf DVT
pt preference, usually do 2 week follow up scan if still there or progressed then use usual recs
PE 2/2 factor V leiden, while on apixiban, what should we do?
LMWH chest 2016. If on LMWH increase dose on it. Get heme c/s. (cancer pts).
when consider op chemoprophylaixs ?
only cancer + additoinal risk factor.
simple way to destinguish takayasu vs. giant cell aortitis
older in giant cell young in takayasu. Both have fever but takayasu higher? left subclavian is class location for takasysu
subclavian stenosis after a “funky febrile illness”
Takaysu endartitis (classic)
bifid uvula
loeys-dietz syndrome, ehlers-danlos
name the 4 important aortic genetic dz assoc with aneursyms and tell at least 2 common clinical features and their genetic defect
- marfans - ectopia lentis, AVMs brain, skeltal features, fibrillin (FBN-1)
- Loeys-Dietz bifid uvula, hypertelorism TGF-B
- Ehlers-Danlos - tranulscent skin and corea, rupture of a gravid uterus and gi rupture –> Col3A1
- Turners - primary aamenorrheam BAV, coarctation, short, webbed neck 45 X karyotype
bifid uvula / cleft palate
Loeys-Deitz (bad news)
clubbed feet
marfans
FH questions for aortopathy?
TAA, Ao dissection, Bicuspid Ao Valve, cerebral aneurysm
bicusp ao valve
remeber can get aortopathy.
When do we operate
5.5 cm ascending ao, 6.5 desc before the hinge point. b
asc beyond 6 cm 30% risk of rupture lifetime
desc beyond 7 mc 40% lifetime risk of rupture.
when to operate on Asc and desc ao aneursyms
5.5 and 6.5 cm or change in > .5 cm in a year.
when have a marfan patient look up this?
ghent criteria
cut point for genetic dz asc ao
5.0 marfans (could be even smaller if FH of AoD at a smaller diameter or rapily expanding). If she is preggo and has marphans need 4. (treat familial asc like marfans). Loeys Dietz 4.2, CT 4.5, Ehlers danlos 5 bc they dont survive.
FH of ASc Ao key question
if family member dissected, what size ao was before it disseected.
ao replacement main concern
lower ext paresis (csf drainage, LE hypothermia, reimplanation of thoracic branches. )
Thoracic Ao how often to image
yearly but when approaching 5 go to q 6 mo.
Mort with type A
20% at 24 hrs, 50% at 1 month.
post dissection repair follow up imaginga
1, 3 6 12 mo
thoracic dissection
at site of ligamentamentum atriuosum.
2 classifications systemts of Ao dissection
type A (asc,) type B desending (stanford)
Type 1 the entire ao
Type II just the top
type III just the descending.
crescent moon sign on CT or mri ao
inta-mural hematoma.
if AAA ruprtures mort rate
90%
biggest RFs for developing AAA
age and smoking
chichester screening study what size was operated on
6.0 mm (study showed 65 yo man had
females with AAA things to know
more likely to rupture.
who gets AAA screening?
smoking and > 65
viva study
vascular screening or nothing. 3% had a triple A. Men > 65 in denmakr 3.3% with triple A. 0.93 HR and cost reductions
endoleaks 4 types
type I leak at marging of a stented cuff type II retrograde flow through branch vessels excuded from lumen type III blood leaks through graft matieral type IV (stupid)
abd ao repair threshold for repair
men 5.5 and women 5.0 (lower for women)
