Peripheral Vascular Dz Flashcards
atherosclerosis of lower/upper extremities
peripheral arterial disease
risk factors of peripheral arterial disease
smoking
diabetes mellitus
hyperlipidemia
hypertension
presence of PAD is high 10 yr CVD risk
intermittent claudication
ischemic muscle pain and weakness in lower extremities
exacerbated by walking
blood supply is enough for sedentary activity but with activity, unable to walk
pseudoclaudication
lumbar spinal stenosis
not a PAD complication, instead pts experience persistent muscle pain, weakness, and tingling that is exacerbated by STANDING erect
relief while sitting down or flexion at waist when walking
PAD physical exam findings
poor peripheral pushes
ulcerations
skin changes
hair loss
leriche syndrome
severe atherosclerosis of abdominal aorta and iliac arteries
caludication symptoms in buttock, thigh, and hip
erectile dysfunction/impotence
poor femoral pulses
aortoiliac bypass graft is treatment
complications of PAD
claudication
ischemic ulcerations of lower extremities
amputations
increased risk of cardiovascular event
PAD diagnosis
clinical suspicion + Ankle Brachial Index
ABI classifications of PAD:
> 1.3
non-compressible and calcified vessel
ABI classifications of PAD:
0.91-1.30
normal
ABI classifications of PAD:
0.41-0.90
mild to moderate PAD
ABI classifications of PAD:
0.-0.4
severe PAD
clinical classification of PAD
can be mild, moderate, severe, etc.
rutherford symptoms classification (severity of claudication)
fontaine classification (walking distances provoke claudication)
PAD management
treatment of atherosclerosis risk factors, lifestyle modification, anti platelet therapy
HTN, DM, HLD, Smoking
LDL <100
aspirin or clopidogrel (morality decrease)
cilostazol, pentoxifylline (symptom benefit)
Revascularization
done to treat PAD
- percutaneous revas. (stent, small stenosis)
- arterial bypass (large area, severe claudication, ALI)
acute limb ischemia
sudden occlusion of lower extremity artery secondary to arterial embolism, thrombosis in situ
acute limb ischemia symptoms
sudden onset of claudication symptoms: PAD 6 Ps
pain, pallor, pulselessness, polikilothermia, paresthesia, paralysis
crescendo pattern
treatment of acute limb ischemia
anticoagulation
smaller occlusion = stent, larger = bypass
may have to treat gangrene
types of gangrene
dry gangrene
gas gangrene
wet gangrene
general pathophys of gangrene
tissue loses blood supply and undergoes necrosis
dry gangrene
develops from ischemic tissue where blood supply is inadequate to keep tissue viable
so tissue undergoing sterile ischemic coagulative necrosis
clear tissue margins
wet gangrene
stagnant blood flow promotes rapid growth of bacteria
characterized by thriving bacteria
tissue swells and emit awful smell, can cause sepsis
gas gangrene
myonecrosis that can progress to necrotizing fasciitis
at first skin is normal but pain is out of proportionate
eventually will have sepsis symptoms, palpable crackles, dish water discharge
characteristics of necrotizing skin infections
spectrum of illnesses, characterized by
fulminant, extensive soft tissue necrosis, systemic toxicity, high mortality
risk factors for necrotizing skin infections
DM, alcoholism, age, peripheral vascular disease, renal failure, HIV, IV drug abuse
pathophys of gas gangrene
direct invasion of subQ tissue from external trauma
bacteria proliferate, invade subQ tissue and deep fascia
causes ischemia, liquefaction, and systemic toxicity
diagnosis of gas gangrene
clinical suspicion + extremity x rays, CTA, MRI, emergent surgical consult, angiograms
treatment of gas gangrene
aggressive IV fluids
broad spectrum ABX
emergent debridement or amputations
hyperbaric oxygen
aortic aneurysm
dilation of aorta due to weakening of blood vessel wall
risk rupture of hemorrhage, arterial branch stenosis or occlusion
aortic aneurysm
mortality
risk of rupture increases exponentially above 5cm diameter
larger risk the bigger it is
risk factors for aortic aneurysm
atherosclerosis
rustic medial necrosis (marfan syndrome and ehlers dances)
vasculitis (takayasu, giant cell)
chronic infection
trauma
clinical features of marfan features
arachnodactyly
ectopic lentis
long slender limbs
murmurs
aortic aneurysm and disseaction
clinical presentation of abdominal aortic aneurysms
compression of adjacent structures causes symptoms
mural wall thrombus may form that causes lower extremity ischemia
iliac aneurysms can comprise ureter and cause hydronephrosis
pulsatile mass below umbilicus
clinical presentation of AAA
if they rupture –> abdominal pain, hypotension
cardiovascular emergency
high mortality
AAA diagnosis
duplex ultrasonography to screen then CT angiogram for diagnosis
** In emergencies, CT angiograms are used
management of AAA
< 5.5 cm
smoking cessation
tight blood pressure control (Beta blockers)
cholesterol reduction
management of AAA
> 5.5 cm
surgery
open gortex graft or EVAR
acute aortic syndromes
aortic dissections
incomplete dissection
intramural hematoma
penetrating ulcer
aortic dissection
dissection of blood into intimal layers results in false lumen parallel to true lumen
risk factors of
aortic dissection
hypertension
connective tissue disease
trauma
cocaine use
aortic coarctation
vasculitis
aortic dissection
mortality
if the arch is involved, 50% mortality in first 48hrs , 90% in first month
clinical presentation
aortic dissection
sudden chest pain and/or back pain
abdominal pain
proximal dissection - coronary A. and MI
cardiac tamponade
diagnosis of aortic dissection
must have high clinical suspicion
“tearing chest or backspin”
chest Xray, CT angiogram, MRA
aortic dissection management
ICU management
blood pressure reduction
stanford A- surgical therapy + medical therapy
stanford B- medical therapy alone
acute mesenteric ischemia
etiologies
arterial embolism
atherosclerosis in situ thrombosis
vasospasm of mesenteric arterial system causing decrease flow
consider an embolism as a cause of acute mesenteric ischemia if:
sudden onset of pain
risk factor: atrial fibrillation
consider a thrombus as a cause of acute mesenteric ischemia
history of PAD causes a plaque to rupture and develop a thrombus lodged in mesenteric a.
abdominal pain worsened with eating
slower presentation, causes unintentional weight loss
consider non occlusive etiology if acute mesenteric ischemia
angina of the gut
clinical features of acute mesenteric ischemia
severe abdominal pain ( out of proportion to exam)
no peritoneal signs (i.e. guarding or rebound)
may have melena or hematochezia
pts will appear very ill
diagnosis of acute mesenteric ischemia
lactate elevation
CT Abd/pelvis with contrast = “thumb printing” sign, portal venous gas, pneumatosis intestinalis
pathoneumonic findings of acute mesenteric ischemia
Thumbprining sign on a plain x ray
portal venous gas
pneumatosis intestinalis
compared to acute mesenteric ischemia, acute colonic ischemia has
patients are not very ill
risk factors are aortic or iliac artery, MI, cardiac bypass, drug side effects, etc.
acute mesenteric ischemia tx
surgical resection
specific acute mesenteric ischemia tx = arterial emboli or thrombosis
IV hydration
pain management
vascular surgery consult
chronic mesenteric ischemia treatment
angioplasty with stent
surgical bypass
pathophysiology of vasculitis
inflammation of blood vessels due to infection, connective tissue disorder, or idiopathic
idiopathic vasculitis
buerger disease
non atherosclerotic diseases of small peripheral arteries, veins, nerves
found in young men who smoke
claudication symptoms and necrotic eschar
buerger disease diagnosis
young smoking male
no evidence of atherosclerosis or emboli
segmental occlusion to small vessels and cork screw collaterals on CTA
buerger disease treatment
smoking cessation (halt progression)
iloprost (systemic vasodilator)
vascular surgery
Raynaud’s phenomenon
vasospastic disease of small arteries
primary (no underlying disease) and secondary (autoimmune, buerger disease, drugs)
Raynaud’s phenomenon
primary features (sex, age, freq., other)
mc in female, adolescents, daily episodes
No finger edema, perilungual erythema, arthritis, no autoantibodies
Raynaud’s phenomenon
secondary features
male or female, 20-30s, weekly/monthly episodes
common finger edema and redness, arthritis, and autoantibodies
clinical features of Raynaud phenomenon
recurrent episodes of color changes to toes, fingers, nose, ears due to vasospasm of digital arteries
white (pallor) –> blue (cyanosis) –> red (reactive hyperemia)
Raynaud phenomenon
treatment
avoidance of triggers
calcium channel blockers
Takayasu arteritis
pathophysiology
idiopathic granulomatous vasculitis of aorta, branches, and pulmonary artery
granulomatous inflammation in vessel wall results in stenosis and aneurysm
Takayasu arteritis epidemiology
young asian women
Takayasu arteritis clinical features
history of fatigue, weight loss, low grade fevers
cool extremities, caludicaiton or numbness, syncope
Takayasu arteritis
physical exam findings
hypertension of stenosis of renal artery or coarctation of Aorta
aortic regurgitation murmur heard on left sternal border
Takayasu arteritis diagnosis
clinical presentation consistent
angiogram evidence of stenosis of Aorta or branches
Takayasu arteritis treatment
corticosteroids
vascular surgery consultant
giant cell arteritis
epidemiology
more common in females 50+
males more likely to go blind
temporal arteritis
pathophysiology
vasculitis of temporal arteries + subclavian, axillary, and aortic a.
causes ocular blindness due to occlusion of retinal artery
clinical features of giant cell arteritis
jaw claudication, retinal a. occlusion
syndrome of pain of shoulder/hip
tender temoral pulse
cherry red spot
diagnosis of giant cell arteritis
elevated ESR and CRP
temporal artery biopsy (shows inflammation)
tx: of high dose corticosteroids
AV malformations
abnormal communications that shunt blood from arteries to veins bypassing the capillaries
can be seen in hereditary hemorrhagic telangiectasia
varies veins/venous insufficiency
dilated tortuous veins of lower extremities, gradual and painful development
caused by venous insufficiency (poor valvular function causes pooling of blood)
venous insufficiency risk factors
smoking deep vein thrombosis sedentary lifestyle/obesity lower extremities trauma pregnancy
clinical présentations of venous insufficiency
skin changes
lower extremity edema
leg pain/heaviness
venous insufficiency diagnosis
venous duplex ultrasound
venous insufficiency treatment
elevation
compression stockings
silver dressings
escin
phlebitis v. thrombophlebitis
thrombophlebitis - inflammation and confirmed thrombus
phlebitis is just inflammation
signs and symptoms of phlebitis
pain, tenderness, redness, swelling
vein feels like palpable cord
risk factors off phlebitis
IV sites, esp/ potassium
hypercoaguable conditions
thrombophlebitis migrans
thrombophlebitis migrans
migrating thrombophlebitis due to thrombosis of superficial veins in multiple ares of body
associated with adenocarcinoma
virchows tirad
endothelial injury
venous stasis
hypercoagulation
DVT to PE
thrombus forms in calf and breaks off, travels thru heat to pulmonary artery
blocks blood flow causing hypoxia and decreased preload
DVT clinical manifestations
unilateral calf/leg swelling
Homans sign (pain w/dorsiflexion)
warmth/tenderness
Wells Criteria for DVT
add one point for: cancer, paralysis, bedridden, tenderness, leg swollen, calf swollen, pitting edema, collateral superficial vein, previous documented DVT
score of 3+= high probability, 1 or 2= moderate, 0= low
low probability of DVT work up
D-dimer
if elevated, u/s
if normal, it’s not DVT
moderate to high DVT probability
venous doppler u/s of lower extremities
modified wells criteria
diagnoses PE, >4 - likely
3 points: clinical DVY, ddx is less likely
- 5: HR >100 bpm, immobilization, previous PE/DVT
1: hemoptysis, malignancy
PERC
8
used if pts have low probability of PE , if patients meet all 8 likely not PE
age <50 hr < 100 bpm O2 sat <95% no memoptysis no estrogen use no history of DVT/PE no unilateral swelling no surgery or trauma
gold standard for PE diagnosis
CTPA
be careful, risk of AKI with contrast
if risk is there do a VQ scan
other testing for PE
EKG (S1-Q3-T3)
ABG, Chest X RAY (westermark sign, ham-tom’s hump)
