Peripheral Vascular Disease Flashcards
You diagnose a patient with PVD and she asks you how she could’ve developed this disease. How do you answer?
- Structural changes in vessel wall
- Narrowing of vascular lumen
- Spasm
What is the normal diameter of the aorta from the base of the heart?
3 cm from origin at base of heart
A patients ascending aorta is 7cm. Is this normal?
No. The normal ascending aorta diameter is 5 – 6 cm length
A patients descending aorta is 1cm. Is this normal?
No. The normal descending aortal diameter 2 – 2.5 cm
If a patients abdominal aorta is 1.8–is this ok?
Yes: Narrows 1.7 – 1.9 cm
As the aorta pierces the diaphragm, it becomes the abdominal aorta
What is an Aortic aneurysm?
Abnormal localized dilatation of an artery
Diameter has increased by at least 50% compared with normal
T/F: A TRUE aortic aneurysm is a dilation of all 3 layers.
True
What is a fusiform aortic aneurysm?
Fusiform – symmetrical dilation of entire circumference (most common)
What is a saccular aneurysm?
localized out-pouching involving only a portion of circumference
What is the most common type of aortic aneurysm?
Fusiform
What is a False/Pseudoaneurysm?
Contained rupture of the vessel wall–
–that develops when blood leaks out of the vessel lumen
–through a hole in the intimal and medial layers
–and is contained by layer of adventitia or perivascular organized thrombus
Where do pseudo aneurysms develop? Are they stable?
Develop at sites of vessel injury – infection, trauma, puncture
No; they are very unstable and prone to rupture
A patient has an ascending aortic aneurysm, what are some possible causes?
Aging
HTN
Connective tissue disorders (Marfan’s)
Bicuspid aortic valve
If a patient had atherosclerosis and its associated risk factors, what could this ultimately cause?
Descending thoracic and abdominal aortic aneurysms
T or F: Ascending aortic aneurysms are more common in women
False
More common in men
You suspect your male patient has an aortic aneurysm, what type is it most likely to be?
Fusiform
often extend into the aortic arch
What condition predisposes patients to an aneurysm and dissection?
Bicuspid aortic valve
Where do descending thoracic aortic aneurysms begin?
Often begin distal to left subclavian artery
A patient with a descending thoracic aortic aneurysm may have what other predisposing condition?
Coarctation of the aorta
What is the most common type of descending aortic aneurysm?
Fusiform
Where are >90% of abdominal aneurysms?
distal to the renal arteries
“infrarenal abdominal aneurysms”
What are the risks for an AAA?
1. Smoking increases risk 8x in ADAM 2. HTN present in 40% of patients 3. Family history and presence of COPD are also cofactors 4. Cholesterol may play a role
What are some other causes of true aneurysms?
- Infection
2. Vasculitis – Takayasu arteritis, giant cell arteritis
When a patient has a symptomatic aortic aneurysm, what are the symptoms most likely attributed to?
compression of other structures
A patient presents with cough, dyspnea, pneumonia, you know this patient has a coarctation of the aorta–what else is going on with this patient?
A thoracic aneurysm that is compressing the mainstem bronchus
How would a patient with an aortic aneurysm present if they are having esophageal compression?
dysphagia
hoarseness
If a patient with an AA presents with back pain and nonspecific GI symptoms, what should you be suspicious of?
AAA
Match these clinical presentations correctly:
- Ascending aneurysm
- Descending aneurysm
- Thoracoabdominal aneurysms
Answer choices:
a. Back / left flank pain
b. Pain anteriorly, under the breast bone
c. Interscapular region / upper back discomfort
- Ascending aneurysm
b. Pain anteriorly, under the breast bone - Descending aneurysm
c. Interscapular region / upper back discomfort - Thoracoabdominal aneurysms
a. Back / left flank pain
What would you expect to find on physical exam for a patient with AA?
- Pulsatile mass
- Murmur aortic regurgitation*
- Features of Marfan’s syndrome
Incidental finding on imaging
What tests would you order when wanting to diagnose AA?
- U/S
- Contrast enhanced CT
- MRA
What is the most useful and least expensive mode of diagnosis of an AA?
U/S
What is the best used to assess progression of AAA size?
U/S
What is the average expansion of an AAA? What about a thoracic aneurysm?
- 4 cm/year AAA and
0. 1 cm/year thoracic
A patient was brought to the ED with severe pain, LOC, shock, and ultimately unfortunately died. Explain this situation. What was the cause of death? Why did this happen?
The patient’s death was a result of massive internal hemorrhage.
There was an aortic rupture
What aortic aneurysm rupture diameter is a “ticking time bomb” ?
> 6cm
A patient is diagnosed with AA and refuses treatment. He wants to know how long he has to live?
Average survival if untreated is 17 months
How do you treat Aortic Aneurysm?
Based on size and patient’s overall medical conditions
Close monitoring every 6 – 12 months if asymptomatic
Elective surgical intervention if symptomatic (regardless of size)
What are Indications for surgical repair for an AA patient?
- Ascending Aortic Aneurysm
> 5.5 cm
Marfan’s syndrome > 5.0 cm - Descending Aortic Aneurysm
> 6.5 cm
Marfan’s syndrome > 6.0 cm - Abdominal Aortic Aneurysm
>5.5 cm, and/or
growth > 1.0 cm/year
What is an aortic dissection?
Occurs when the blood-filled channel divides medial layers of aorta, splitting intima from adventitia
Paint the “Poster patient” for aortic dissection.
A 65 year old men with HTN and a h/o of cocaine abuse
What is the MC cause for dissection in patients <40 years old?
Marfan syndrome
pregnancy
Where do most of aortic dissections occur?
Ascending thoracic aorta
What is a Type A dissection?
Proximal: if ascending aorta involved
2/3 of cases
What is a type B dissection?
if occurs beyond left subclavian artery
does not involve ascending aorta
Acute vs Chronic dissection?
symptoms of less than 2 weeks duration
A patient is having anterior, substernal chest pain–what type of dissection is this?
Type A
Scapular/back pain is associated with which dissection?
Type B
What should you always consider in your differential diagnosis if the patient is complaining of chest, abdominal or back pain?!
aortic dissection and
ruptured thoracic or abdominal aneurysm
How helpful is a CT angiography with an aortic dissection?
Can effectively exclude the major forms of life-threatening thoracic pathology
Biomarker indicating activation of the coagulation system
D dimer
What does a negative D dimer mean?
excludes acute aortic dissection
This is a good thing. You want it to be negative.
A patient is diagnosed with Aortic dissection. What complications are a possibility?
- Pericardial tamponade
- Stroke
- MI
- Renal failure
- Limb ischemia
- Aortic regurgitation
A patient was diagnosed with Aortic dissection and he wants to know what treatments are available. How do you respond?
- Goal – arrest progression of dissection
- If suspicion of dissection
- -Reduce SBP
- -Decrease force of LV contraction
- —IV NTG, sodium nitroprusside, BBs, vasodilators
How should you treat Type A aortic dissection?
Early surgical correction indicated
High risk for death, intrapericardial rupture, aortic reguritation or MI
How is Type B aortic dissection treated?
Initially aggressive medical therapy alone
BB + afterload reducer
When is surgery indicated for a Type B aortic dissection?
- continued propagation
- compromise of major branches of aorta
- impending rupture
- continued pain
For which type (A or B) dissection is early surgical intervention indicated?
-Type A
Early surgical intervention does not improve outcome for Type B*
Which type of aortic dissection has a high risk for death, intrapericardial rupture, aortic reguritation or MI?
Type A
Formation of atherosclerotic plaques in large and medium-sized arteries
Peripheral Arterial Disease
What are risk factors of PAD?
Cigarette smoking
Diabetes mellitus
Dyslipidemia
Hypertension
A patient is having buttock, thigh and calf discomfort, precipitated by walking, relieved by rest, claudication. What is their diagnosis?
Peripheral arterial disease
What sxs are associated with Severe PAD?
Pain at rest, feet & toes
Prone to ulcerations
What can you expect to find on physical exam of a patient with PAD?
- Bruits
- Loss of pulses distal to stenotic segment
- Muscle atrophy
- Pallor
- Cyanotic discoloration
- Hair loss
- Ischemic ulcers – toes, lateral malleolus, painful
This type of ulceration describes what kind of PAD?
Trauma heels / toes Painful Discrete edges - “punched out” Edges covered with crust Infected --> erythematous Rapidly developing
Arterial
Describe the ulceration associated with Venous PAD.
- Leads to stasis ulceration
- Painless
- Ankle / lower leg above medial malleolus
- Reddened, thickened over medial malleolus
- Cobblestone appearance
- Occurs with slightest trauma
- Slow developing
What are the diagnostic studies for PAD?
- ABI
- Duplex ultrasonography
- MRA
- CTA
- Intra-arterial contrast angiography
How do you take the Ankle-Brachial Index (ABI)?
Measure systolic BP with Doppler in
each arm and
dorsalis pedis and posterior tibial pulses
Divide the ankle pressure by the arm pressure bilaterally
Which Ankle-Brachial index is diagnostic of PAD?
<0.9
Usually with symptoms of intermittent claudication
Which Ankle-brachial index is diagnostic of severe PAD?
- Severe PAD with critical leg ischemia
- Often have pain at rest
What treatment do you give for all PAD patients?
- Antiplatelet therapy**
- - ASA – shown to reduce CV morbidity and mortality - Risk factor modification**
- Supportive care of feet / prevent trauma
- Formal exercise program – 1st line treatment
- Medical therapy
What does “medical therapy” consist of with PAD?
- Cilostazol (Pletal)
Selective phosphodiesterase inhibitor
Vasodilator and platelet inhibitor properties
Improves exercise capacity - Pentoxifylline (Trental)
Improve deformability of RBC & WBC
May improve claudication symptoms
Cilostazol (Pletal)
Used for PAD
Selective phosphodiesterase inhibitor
Vasodilator and platelet inhibitor properties
Improves exercise capacity
Pentoxifylline (Trental)
Improve deformability of RBC & WBC
May improve claudication symptoms
When is revascularization indicated for PAD?
–Indicated after failed medical therapy
–Or in cases of severe limb ischemia
Goal – heal ulcers, prevent limb loss
–PTA (percutaneous transluminal angioplasty)
–Surgery
What is Acute Aortic Arterial occlusion usually caused by?
embolization or thrombus Origin of arterial emboli usually cardiac Mitral stenosis Atrial fibrillation Acute AWMI Infective endocarditis
T or F: Acute Arterial Occlusions rarely originate from venous circulation
True
What is a Paradoxical embolism?
Arterial embolism from venous circulation
Clot passes through an abnormal intracardiac communication (ASD, VSD, PFO)
A patient comes in with abrupt onset of severe pain in his lumbar area, buttocks, perineum, abdomen and legs. What other associated sxs would you expect to see?
Diffuse cyanosis
From umbilicus to feet
Lower limbs pale and cold
Numbness, paresthesia, and paralysis
Absent pulses of lower limbs
In a patient with Acute Arterial Occlusion, what does muscle necrosis produce?
myoglobinuria, renal failure, acidosis, hyperkalemia and death unless circulation restored promptly
What is the treatment of Acute Arterial Occlusion?
- Anticoagulation
- Immediate revascularization procedure: limb viability at risk
High mortality rate
“Pulseless disease” or “aortic arch syndrome”
Takayasu Arteritis
A female asian patient comes in with malaise, fever, nausea, vomiting, weight loss, rash, arthralgia, and Raynaud phenomenon. What state of what specific condition does she have?
“Pre-pulseless” phase
Takayasu Arteritis
In a Takayasu Arteritis patient, when should you see UE claudication? And what area is this from?
Once arterial obstruction develops–and it is from the subclavian artery stenosis
In a Takayasu Arteritis patient, what does Absent or diminished carotid or limb pulses mean?
Arterial obstruction has developed
UE claudification from subclavian artery stenosis
In a Takayasu Arteritis patient, what does malignant HTN suggest?
Narrowing of the aorta proximal to renal arteries
With a Takayasu Arteritis patient, what causes the cardiac manifestations?
- Severe HTN,
- Dilatation of aortic root,
- Coronary artery stenosis
How do you diagnose Takayasu Arteritis?
- Onset by age 40
- Upper-extremity claudication
- Diminished brachial pulses
- Greater than 10mmHg difference between SBP in arms
- Subclavian or aortic bruit
- Narrowing of the aorta or a major branch
-Presence of 3 of the 6 carries high diagnostic accuracy
How do you treat Takayasu Arteritis?
- Steroid and cytotoxic drugs reduce inflammation
2. Surgical bypass
Chronic vasculitis, medium to large arteries
Most commonly involve cranial vessels or aortic arch and branches
Giant Cell Arteritis (Temporal)
A type of arteritis that may be associated with polymyalgia rheumatica
Giant Cell Arteritis (Temporal)
A patient comes in complaining of facial pain and claudication of the jaw while chewing. Upon Physical exam you note diminished temporal pulses, Impaired vision (15 – 20% patients), Amaurosis fugax. What is the diagnosis?
Giant Cell Arteritis (Temporal)
A patient comes in complaining of facial pain and claudication of the jaw while chewing. Upon Physical exam you note diminished temporal pulses, Impaired vision (15 – 20% patients), Amaurosis fugax. What is the treatment?
Do not wait on result of biopsy to start treatment!!
High-dose steroids
40 – 60 mg daily
Self-limited course 1 – 5 years
A patient comes in complaining of facial pain and claudication of the jaw while chewing. Upon Physical exam you note diminished temporal pulses, Impaired vision (15 – 20% patients), Amaurosis fugax. Explain your lab/study findings.
- ESR and C-reactive protein elevated
- Ultrasound – demonstrates hypoechoic halo around involved vessel
- Diagnosis confirmed by biopsy of t`emporal artery
Classically defined as episodes of discoloration of white ischemia, then blue stasis, then red hyperemia (recovery phase)
Raynaud Phenomenon
What is the pathophysiology behind Raynaud Phenomenon?
Extreme vasoconstriction that temporarily obliterates vessel lumen
Cold exposure or emotional stress triggers spasms
Raynaud Phenomenon
White?
Blue?
Red?
White – finger and/or toes interruption of blood flow
Cyanosis – local accumulation of desaturated hemoglobin
Ruddy color – blood flow resumes
Secondary Raynaud phenomenon (symptoms caused by another etiology)
- Connective tissue disorder
- -Scleroderma, SLE - Arterial occlusive disorders
- Thoracic outlet syndrome
- Blood dycrasias
- Thermal or vibration injuries
- Carpal tunnel syndrome
- Drugs
A patient comes in with atrophy of skin, subcutaneous tissues, muscle. Does not have ulceration, but it seems he has ischemic gangrene. What is your diagnosis?
Raynaud Phenomenon
What are general measures for Raynaud’s patients?
- Avoidance of any environmental triggers, e.g. cold, vibration, etc.
- Warm clothing for the extremities such as mittens
- Smoking cessation.
What are some emergency measures for Raynaud’s patients?
If white finger occurs unexpectedly and a source of warm water is available
allow tepid to slightly warm water to run over the affected digits while gently massaging the area.
Continue this process until the white area turns pink or a normal healthy color.
If triggered by exposure in a cold environment, and no warm water is available
place the affected digits in a warm body cavity - arm pit, crotch, or even in the mouth.
Keep the affected area warm at least until the whiteness returns to pink or a healthy color, avoid continued exposure to the cold.
What are some drug therapies for Raynaud’s patients?
Prevent vasospasm
Calcium channel blockers
α-adrenergic blockers
Dilated, tortuous superficial vessels
Common in lower extremities, especially saphenous veins
Varicose Veins
What do Varicose veins result from?
- Intrinsic weakness of vessel wall
- Increased intraluminal pressure
- Congenital defects of valves
A patient with these factors is likely suffering from which type of varicose veins?
- Familial
- Superficial system
- Pregnancy, prolonged standing, obesity
Primary
A patient with secondary varicose veins will have what associations?
- Abnormality of deep venous system causes superficial varicosities
- -Incompetent perforating veins
- -Deep venous insufficiency or occlusion (DVT)
- -Arteriovenous fistulas
What are some sxs for Varicose vein patients?
Many asymptomatic
- Burning, bursting, bruised, or aching
- Exacerbated by prolonged standing or volume overload states
- Elevation relieves symptoms
What is some treatment for patients with varicose veins?
- Sought for cosmetic reasons
- Elevate legs while supine
- Avoid prolong standing
- Wear external compression stockings
- Injection of sclerosing agent
- Laser – small veins
- Radiofrequency ablation and surgical vein ligation
What is a thrombus composed of initially?
platelets and fibrin
Later RBCs become interspersed within fibrin
Thrombus tends to propagate in direction of blood flow
