Peripheral Vascular Disease Flashcards by Katie Keller

Peripheral vascular disease results from what causes?

Structural changes in vessel walls
Narrowing of vascular lumen
Spasms

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Abnormal localized dilatation of an artery

Diameter has increased by at least 50% compared with normal

Aneurysm

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What is the normal aortic diameter in men and women?

males = 2cm
females = 1.8cm

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What percentage of aortic aneurysms originate at or below the renal arteries?

90%

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List some risk factors for developing an aortic aneurysm?

Smoking
HTN
Increased lipids
obesity

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What is the size of the artery have to measure to be considered an aneurysm?

> 3cm diameter

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At what size of an aneurysm do we worry about rupturing?

> 5cm

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> 10% of aortic aneurysms

Most are asymptomatic

Most are due to atherosclerosis (but also connective tissue disorders)

Thoracic Aortic Aneurysms

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Regardless of the type of thoracic aortic aneurysm, rupture is catastrophic because why?

bleeding rarely contained

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What is the imaging of choice for thoracic aneurysms?

CT scan

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For abdominal aortic aneurysms:

Most useful and least expensive mode of diagnosis

Diagnostic study of choice for initial screening, with routine follow up

Abdominal ultrasound

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For abdominal aortic aneurysms:

More accurately assess size and determines anatomy

Demonstrates arteries above and below aneurysm

Visualization is necessary for planning repair

Contrast-enhanced CT or CTA

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What is the most common complication of an abdominal aortic aneurysm repair and the leading cause of death?

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Life-threatening condition

A true emergency requiring immediate control of BP to limit extent of dissection

Most common aortic catastrophe

Aortic Dissection

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What is the pathophysiology of an aortic dissection?

spontaneous intimal tear creates false lumen between media and adventitia

Blood-filled channel divides medial layers of aorta, splitting intima from adventitia

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Abuse of what substance is increasingly recognized as a predisposing risk factor for aortic dissections?

Cocaine abuse

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What are the most common causes for dissection in patients ages <40?

Marfan syndrome

pregnancy

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What is the most common location for aortic dissections?

Ascending thoracic aorta

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List some risk factors for aortic dissections

HTN – 80%
Marfan Syndrome/coarctation of aorta
Pregnancy
Bicuspid aortic valve
Cocaine abuse

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Which type of aortic dissections carry the worst prognosis?

Type A

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What type of aortic dissections is described below?

Proximal

If ascending aorta involved

Arch proximal to the left of subclavian artery

2/3 of cases

Type A

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What type of aortic dissections is described below?

Distal

If occurs beyond left subclavian artery

Proximal descending thoracic aorta just beyond left subclavian artery

Does not involve the ascending aorta

Type B

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What is a key finding on a CXR to suspect an aortic dissection?

Widened mediastinum

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What is the immediate diagnostic imaging study of choice in aortic dissections, especially in acute situations?

CT chest/abdomen

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List some complications of aortic dissection

Pericardial tamponade Stroke MI Renal failure Limb ischemia Aortic regurgitation death

What is the mortality rate for untreated dissections?

>90%

What is the most common complaint in peripheral artery disease?

Claudication

Development of occlusive atherosclerosic lesions in the extremities Evidence of systemic atherosclerotic process Formation of atherosclerotic plaques in large and medium-sized arteries

Peripheral Artery Disease

List some risk factors for the development of peripheral artery disease

Cigarette smoking Diabetes mellitus Dyslipidemia Hypertension Male gender Increasing age

What is the hallmark of chronic venous insufficiency?

shallow, large ulcer located over the medial malleolus

In PAD, these ulcers found on physical exam suggest what source is affected- artery or vein? Small, deep, painful ulcers (may be painless in diabetics) Trauma heels/toes Discrete edges – “punched out” Edges covered with crust Infected erythematous Rapidly developing

artery

In PAD, these ulcers found on physical exam suggest what source is affected- artery or vein? Painless Ankle/lower leg above medial malleolus Reddened, thickened over medial malleolus Cobblestone appearance Occurs with slightest trauma Slow developing

venous

What is the diagnostic study of choice in PAD?

Ankle-brachial index (ABI)

What reading is considered normal in the Ankle-brachial index (ABI)?

1.0-1.3: normal Ankle pressure is equal to or slightly greater than that in the arms

What reading is diagnostic of PAD in the Ankle-brachial index (ABI)?

<0.9

What is the first line treatment of PAD?

Formal exercise program

What therapy has shown in PAD to reduce CV morbidity and mortality?

ASA (anti-platelet therapy)

What lifestyle modifications in PAD you should educate your patient about?

Smoking cessation Lipid management HTN management DM management Weight loss

In PAD, this therapy is indicated after failed medical therapy, or cases of severe limb ischemia Goal – heal ulcers, prevent limb loss

Revascularization

Poorest prognosis is for those patients with PAD and what underlying disease?

Diabetes

Abrupt total, or near-total occlusion of terminal aorta or common iliac arteries poses immediate threat to life and limb Caused by embolization or thrombus Origin of arterial emboli usually cardiac, rarely originate from venous circulation

Acute Aortic Occlusion

An arterial embolism from venous circulation is called what? Clot passes through an abnormal intracardiac communication (ASD, VSD, PFO)

Paradoxical embolism

What is the clinical presentation of an acute aortic occlusion?

Abrupt onset of severe pain Diffuse cyanosis Numbness Paresthesia Paralysis Absent pulses of lower limbs

What is the treatment of an acute aortic occlusion?

Anticoagulation Immediate revascularization procedure: limb viability at risk

In arterial embolism/thrombosis, most emboli arise from where?

the heart

What is the most common cause of emboli arising from the heart?

Afib

6 “Ps” of acute ischemia = sudden onset in affected limb

Pain (early) Paresthesias (early) Pallor Pulselessness Poikilothermia paralysis

What are the three causes of acute limb ischemia?

Embolic thrombotic traumatic

What is the diagnostic imaging of choice in arterial embolism/thrombosis?

Doppler US

In arterial embolism/thrombosis, immediate revascularization is essential within how many hours of symptom onset?

3 hours

In arterial embolism/thrombosis, irreversible tissue damage and amputating starts after how many hours of symptom onset?

6 hours

In arterial embolism/thrombosis prognosis, what is the percentage risk of resulting in an amputation?

10-25%

In the absence of Afib, what percentage of emboli originate from proximal internal carotid artery?

90%

What is imaging/screening modality of choice for occlusive cerebrovascular disease?

Duplex US is imaging/screening

“intestinal angina” Severe postprandial pain, weight loss due to fear of eating Acute v. chronic intestinal ischemia

Visceral Artery Insufficiency

Veins are high capacitance vessels and contain what percentage of total blood volume?

>70%

Dilated, tortuous superficial vessel in lower extremities

Varicose veins

What is the most commonly involved vein in varicose veins?

Greater saphenouos vein

What is the pathophysiology of varicose veins?

Intrinsic weakness of vessel wall Increased intraluminal pressure Congenital defects of valves

List some risk factors for varicose veins

Female Family history Pregnancy Prolonged standing or heavy lifting History of thrombophlebitis obesity

What is the imaging of choice for varicose veins?

Duplex US

What are some signs/symptoms of varicose veins?

Many are asymptomatic (cosmetic problem - dilated, tortuous veins beneath the skin in thigh and leg visible upon standing) Burning Bursting Bruised Dull, aching heaviness or a feeling of fatigue with prolonged standing Elevation relieves symptoms Worsened with prolonged standing/volume overload states Signs of chronic venous insufficiency (Brownish pigmentation and thinning skin above ankle)

Thrombus tends to propagate in what direction?

direction of blood flow

What are the two kinds of venous thrombosis?

Superficial thrombophlebitis Deep vein thrombosis (DVT)

Thrombus formation within superficial or deep vein Initially thrombus composed of platelets and fibrin Later RBCs become interspersed within fibrin

Venous Thrombosis

Benign disorder Inflammation and thrombosis of superficial vein Tender, erythematous, indurated lesion in the course of a superficial vein

Superficial Thrombophlebitis

What superficial vein is most commonly affected in superficial thrombophlebitis?

Long saphenous most common

What symptoms suggest septic phlebitis (requires urgent treatment) in cases of superficial thrombophlebitis?

Fever, chills, pain at site

What are the risk factors for superficial thrombophlebitis?

Short term venous catheterization May occur as a complication of an in-dwelling IV catheter Varicose veins or thromboangiitis obliterans (Berger’s disease) Pregnancy or post-partum Trauma Abdominal cancer

Superficial thrombophlebitis is associated with occult DVT in what percentage of cases?

20%

What is the treatment for uncomplicated superficial thrombophlebitis?

Symptomatic: Local heat, rest, ASA or anti-inflammatory (NSAIDs)

Deep venous thrombosis most common location?

veins of calves

For a DVT, why do you need a high index of suspicion?

50% of patients are asymptomatic

DVTs result in what two major consequences?

Pulmonary embolism – main/serious complication Post-phlebitic syndrome

Virchow’s triad - what are the components?

Stasis Vascular damage Hypercoagulability

Calf pain produced by dorsiflexion of foot Nonspecific and unreliable sign – only 50% reliable

Homan’s sign

Byproduct fibrin degradation Highly sensitive for DVT/PE, but not specific

D-Dimer

What is the study of choice for DVTs?

Venous compression duplex ultrasonography

What is the target INR for Warfarin?

INR 2.0-3.0

What is the treatment for DVT and why?

Prevents extension of thrombus and PE/prevents additional clot formation Allow the body’s autolytic system to lyse the clot

DVT with or without PE requires minimum of how many months of anticoagulation?

3 months

What is the preferred initial anticoagulation treatment for a DVT that does not require monitoring?

LMWH

When to use an IVC filter in a patient with DVT?

high risk patients or if anticoagulation is contraindicated

Why does Warfarin need to be bridged with LMWH?

Warfarin can induce a hypercoagulable state during the first few days of administration

Caused by functionally inadequate valve leaflets Scarred, thickened, or in dilated vein that results in abnormally high hydrostatic force transmitted to subcutaneous tissues and veins of the lower legs Causes pronounced edema, creating secondary changes

Chronic Venous Insufficiency

What are the risk factors for chronic venous insufficiency?

History of DVT/phlebitis History of leg trauma Obesity Superficial venous reflux/varicose veins Neoplastic obstruction of pelvic veins Congenital AV fistula

What is primary presenting symptom in chronic venous insufficiency?

Progressive pitting edema of the lower leg

What is the management of chronic venous insufficiency?

Bed rest Leg elevation Graded compression stockings Exercise Wet saline compresses for weeping stasis dermatitis Unna boot, ace wrap, wet to dry saline dressings, hyperbaric chamber for wound treatment Antibiotics and antifungals when indicated