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Cardiovascular > Peripheral Artery Disease Part 2 > Flashcards

Peripheral Artery Disease Part 2 Flashcards

1
Q

What are the essentials of diagnosis of 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

What is the etiology of an acute arterial occlusion?

A

Thrombus or embolus

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3
Q

If a thrombus occurs leading to acute occlusion, what happens?

A

stable atheroma with fibrous plaque ruptures

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4
Q

What is the presentation of a patient with a thrombus leading to acute occlusion?

A
  • Typically history of intermittent claudication
  • May not be as dramatic if hx of PAD due to collaterals
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5
Q

Where do most emboli come from? What is the most common cause?

A

Heart
* Afib
* Atherosclerosis can also cause plaque rupture leading to thrombus that can break off and become an embolus in smaller vessels

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6
Q

What are the 6 P’s of acute occlusion presentation?

A
  • Pallor
  • Pain
  • Pulseless
  • Paralysis
  • Polar/poikilothermia (purple spots)
  • Paresthesias
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7
Q

How is diagnosis of acute occlusion made?

A
  • Most often clinical
  • Doppler with little to no flow in distal vessles
  • Acute imaging (CTA or MRA) avoided if light touch sensation compromised

Would not use acute imaging due to delay in therapy unless in preparation for surgery

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8
Q
A
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9
Q

What other tests can be considered for acute arterial occlusion?

A
  • EKG (see if pt is in afib)
  • CBC, PT/INR, PTT (pre-op assessment)
  • Echo (later if embolic source suspected)
  • BMP, ABG for metabolic acidosis, hyperkalemia, rhabdomyolysis, AKI
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10
Q

How is acute occlusion managed?

A
  • Immediate revascularization if symptomatic within 3 hours
  • Emergent vascular surgery consult for endovascular or open-surgical approach
  • Anticoag with IV heparin bolus and continuous infusion

Longer delays carry risk of irreversible tissue damage, up to 100% at 6 hrs

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11
Q

What should you do for a patient with acute arterial occlusion once stable?

A

Determine source
* If due to PAD thrombus –> treat as other PAD
* Embolus –> determine source and treat underlying cause
* Most require warfarin for 3 + months with INR of 2.0-3.0

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12
Q

What is the prognosis of acute arterial occlusion?

A
  • 10-25% risk of amputation and 25%+ in-hospital mortality rate
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13
Q

What are the essentials of diagnosis of a abdominal aortic aneurysm?

A
  1. Most 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 causes excruciating abdominal pain that radiates to back and hypotension
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14
Q

What is the etiology of AAA?

A
  • Dilatation of infrarenal aorta is part of aging
  • AAA >3 cm (normal aorta = 2 cm)
  • MC in men over 55
  • Most AAA occur below renal arteries (usually aortic bifurcation and common iliac arteries)

Rarely ruptures under 5 cm

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15
Q

What are risk factors for AAA?

A
  • Male gender
  • Family history of AAA
  • Smoking history
  • Increasing age
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16
Q

What are the 2 major groups of AAA?

A
  • Fusiform: circumferential expansion of aorta
  • Saccular: outpouching of a segment of the aorta
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17
Q

What is the presentation of AAA?

A
  • Most asymptomatic found on imaging
  • Symptoms: mild to severe pain over mid-abdomen can radiate to lower back
  • Constant or intermittent
  • Exacerbated by pressure

Most have thrombus lining aneurysm but embolization is rare

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18
Q

What is the presentation of rupture of AAA?

A
  • Severe pain
  • Palpable abdominal mass
  • Hypotension
  • Free rupture into peritoneal cavity is LETHAL :(
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19
Q

How is AAA diagnosed?

A
  • Lab eval only in patients undergoing surgical repair: CBC, BMP, PT/INR, PTT
  • ABD US= diagnostic study of choice for initial screening
  • CT scans = more reliable assessment of aneurysm diameter
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20
Q

When would a CT scan be done for AAA?

A
  • When aneurysm nears diameter threshold (5.5 cm) for treatment
  • For surgical planning: contrast-enhanced CT scans show arteries above and below
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21
Q

What is done once a AAA is identified?

A
  • Routine f/up with ultrasound with frequency depending on size
  • CTA with contrast once measures 5 cm
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22
Q

What is the 15th leadinng cause of death in the US?

A

Ruptured AAA
10th leading cause of death in men older than 55

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23
Q

What are screening recommendations by the USPSTF for AAA?

A

B recommendation:
* One-time screening ultrasound for men 65-75 who have ever smoked
C recommendation:
* Screening men 65-75 who have never smoked with risk factors and family history

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24
Q

How often would you screen by US a aneurysm that is 3-3.4 cm? 3.5-4.4 cm?

A
  • Every 2 years
  • Every 12 months
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25
Q

How often should you screen by US an aneurysm that is 4.5-5.4 cm?

A

Every 6 months
REFER TO VASCULAR SURGERY

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26
Q

When is elective AAA repair indicated?

A
  • Aneurysms >5.5 cm or with rapid expansion
  • Pain or tenderness symptoms
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27
Q

How is AAA rupture managed?

A

Emergent endovascular repair (and 1/2 of those patients survive :()

LETHAL IF NOT REPAIRED

28
Q

How is abdominal inflammation/inflammatory aneurysm treated?

A
  • Treatment of underlying cause (vasculitis, infection, retroperitoneal fibrosis)
  • Surgery if aneurysm >5.5 cm, compression of retroperitoneal structures, or pain with palpation
29
Q

How can a AAA be repaired?

A
  • Open repair
  • Endovascular repair
30
Q

What are the benefits and risks of open repair of AAA?

A
  • Excellent long-term results
  • Higher complication rates
  • Risk of post-op MI
  • Mortality risk (1-5%)
  • Long recovery
31
Q

What are the benefits and risks of endovascular repair?

A
  • Decreased 30 day mortality (.5-2%)
  • Decreased perioperative systemic complications
  • Increased need for secondary procedures b/c of leaks
32
Q

What is the prognosis of AAA post surgical repair?

A

60% alive at 5 years

33
Q

What is the leading cause of death post AAA surgical repair?

A

MI

34
Q

What are the essentials of diagnosis of a thoracic aortic aneurysm?

A
  1. Widened mediastinum on chest radiograph
  2. With rupture, sudden onset chest pain radiating to the back
35
Q

What is the etiology of thoracic aneurysm?

A
  • Most due to atherosclerosis
  • Disorders of connective tissue (Ehlers-Danlos and Marfan) rare causes
  • Bicuspid aortic valve disease rare cause
  • Less than 10% AA in thoracic

Thoracic = above diaphragm

36
Q

What is the presentation of thoracic aneurysms?

A
  • Most asymptomatic
  • Symptoms depending on size and position
  • Substernal back or neck pain
  • If pressure on trachea, esophagus, or superior vena cava: dyspnea, stridor, or brassy cough, dysphagia, edema in neck and arms, distended neck veins
  • Stretching of L recurrent laryngeal nerve –> hoarseness
  • A of Ascending Aorta–> aortic regurgitation due to dilation of aortic valve annulus
37
Q

What happens if thoracic aneurysm bursts?

A

Catastrophic, bleeding rarely contained so no time for repair

38
Q

How is thoracic aortic aneurysm diagnosed?

A
  • Chest x-ray with widened mediastinum
  • CT scan with contrast = modality of choice for anatomy and size
  • MRA
  • Cardiac catheterization and echo
39
Q

Why would a MRA be useful for thoracic aortic aneurysms?

A

Excluse conditions that mimic aneurysms (neoplasms, substernal goiter)

40
Q

Why is cardiac catheterization and echocardiography helpful?

A

Determine relationship of coronary vessels aneurysm of ascending aorta and look at aortic valve

41
Q

How is thoracic aneurysm managed?

A

Surgical repair

42
Q

What does surgical repair depend on?

A
  • Location of dilation
  • Rate of growth
  • Associated symptoms
  • Overall patient condition
43
Q

Which aneurysms should be considered for repair?

A
  • Aneurysms 5.5-6 cm or larger
  • Aneurysms of descending thoracic aorta treated by endovascular grafting
  • Aneurysms of proximal aortic artch/ascending aorta harder
44
Q

What are screening guidelines for thoracic aneurysm?

A
  • No current guidelines
  • Referral to CT surgeon or vascular surgeon at time of diagnosis and monitor size via TTE or CT every 6-24 months
  • Control risk factors and maintain well-controlled BP
45
Q

epair

What are the essentials of diagnosis of aortic dissection?

A
  • Sudden searing chest pain radiating to back, abdomen, or neck in hypertensive patient
  • Widened mediastinum on CXR
  • Pulse discrepancy in extremities
  • Acute aortic regurg may develop
46
Q

How is aortic dissection classified?

A
  • Entry point and distal extent
  • Type A dissection: involves arch proximal to the left subclavian artery
  • Type B dissection: occurs in proximal descending thoracic aorta just beyond left subclavian artery
47
Q

What is the etiology of aortic dissection?

A
  • Spontaneous intimal tear and blood dissects into media of aorta
48
Q

What is the epidemiology of aortic dissection?

A
  • MC in men over 50
49
Q

What are risk factors for aortic dissection?

A
  • Aging
  • Atherosclerosis
  • Increased BP
  • Blunt trauma to chest wall
  • Aortic valve defect
  • Aortic coarctation
  • Pre-existing aortic aneurysm
  • Pregnancy
50
Q

What is the presentation of aortic dissection?

A
  • Severe, persistent, sudden pain that radiates to back and possibly neck
  • Hypertension (usually)
  • S/s of disrupted perfusion to organs
  • Diastolic murmur (if in ascending aorta close to aortic valve)
51
Q

What are signs and symptoms of disrupted perfusion to vital organs that result from aortic dissection?

A
  • Syncope, hemiplegia, or paralysis of lower extremities
  • Intestinal ischemia
  • Renal insufficiency
  • Peripheral pulses may be diminished or unequal
52
Q

What can a diastolic murmur due to aortic dissection cause?

A
  • Valvular regurgitation
  • Heart failure
  • Cardiac tamponade
53
Q

How is aortic dissection diagnosed?

A
  • EKG with LVH
  • Chest X Ray with widened mediastinum
  • CT scan of chest and abdomen with contrast - diagnostic imaging modality of choice
  • TEE (typically takes longer to obtain)
54
Q

How is aortic dissection managed?

A
  • BP control
  • Pain control
  • Surgical intervention
54
Q

What should be used for blood pressure control in aortic dissection?

A
  • Agressive measures if suspected
  • Lower to 100-120 mmHg
  • Beta-blockers = 1st line (labetolol)
  • IV CCBs (nicardipine) or nitroprusside added if not at goal
55
Q

What beta blockers are usually used in aortic dissection management and why?

A
  • Labetolol = alpha and beta blocker, lowers pulse pressure and achieves rapid BP control
  • Esmolol= for patients with asthma, bradycardia, or potential for reaction to beta blockers, has short half life
56
Q

What is used for pain control with aortic dissection?

A

Morphine = drug of choice

57
Q

How is type A dissection managed surgically? Type B?

A
  • Urgent surgical intervention for type A
  • Type B may require urgent surgery if signs of malperfusion of target tissues
58
Q

What are the essentials of diagnosis of thromboangiitis obliterans (Buerger disease)?

A
  1. Typical in male cigarette smokers
  2. Causes severe ischemia of distal extremities progressing to tissue loss
  3. Thrombosis of superficial veins is possible
  4. Smoking cessation is essential
59
Q

What is the etiology of Buerger’s disease?

A
  • Segmental, inflammatory, thrombotic processes in small distal arteries and veins of extremities
  • Cause unknown
  • Pathology shows arteritis

NOT ATHEROSCLEROSIS

60
Q

How does Buergers progress?

A
  • Starts with toes/feet MC plantar and digital vessels of foot/leg
  • Can see hand/finger involvement in advanced stages
  • Severe ischemia can result in tissue loss
61
Q

What is the epidemiology of Buergers?

A
  • Closely linked to tobacco use
  • Male smokers <40 y/o
62
Q

What is the presentation of Buergers?

A
  • Distal ischemic rest pain or ischemic ulcerations on the toes, feet, or fingers
  • Claudication less common
  • Superficial thrombophlebitis possible
  • May progress to proximal arteries, but rarely large arteries
  • Intermittent episodes possible
63
Q

How is Buergers diagnosed?

A

R/O other thromboembolic sources for distal ischemia
* CBC, CMP, Coag studies
* TEE
* Rheumatic testing

  • Arterial duplex
  • CTA or MRA
64
Q

How is Buergers managed?

A
  • Tobacco cessation is only effective treatment
  • Revascularization rarely and option and amputation often required
  • NSAIDs/opioids for pain control in acute ischemic events

No other pharm has been shown to be effective :(

65
Q

What are complications of Buergers?

A
  • Ulcerations
  • Gangrene
  • Infection
66
Q

What is the prognosis for Buergers?

A
  • Patients who stop tobacco use can prevent amputation
  • Continued tobacco use = 8-year amputation rate of 40%
  • Uncommonly causes death

Cardiovascular (17 decks)

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