SM 137 Peripheral Vascular Disease Flashcards by Ashwin Sunderraj

What is Peripheral Arterial Disease?

PAD is stenotic or occlusive arterial disease caused by atherosclerosis outside the heart

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How can PAD present?

PAD may be asymptomatic, but can also present as intermittent claudication and critical limb ischemia

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What is intermittent claudication?

Claudication is pain caused by a lack of blood flow and can be intermittent with worsening during exercise

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What is critical limb ischemia?

Severe lack of blood flow to the limbs that results in severe pain and/or gangrene in the limb

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How does age affect PAD?

PAD worsens with age

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How does the extent of symptoms felt in PAD effect survival?

Severe symptomatic PAD has worse survival than asymptomatic PAD

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How is PAD affected by cadiovascular mortality?

PAD in the setting of MI results in greater long term risks of overall cardiovascular mortality

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What is the Rutherford Class system?

System used to describe Limb Threatening Ischemia, on a scale of 0 - 6

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How does asymptomatic PAD compare to CLTI?

Asymptomatic PAD tends to result in stable claudication while CLTI tends to result mortality or amputation

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What can improve CLTI prognonsis?

CLTI tends to progress to amputation and death, with outcomes being improved by revascularization

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What are the risk factors for PAD?

Atherosclerosis, cigarette smoking, diabetes, hypertension, hyperlipidemia, and family history

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Why does CLTI lead to pain at rest in the setting of PAD?

A mismatch between arterial supply and demand leads to ischemia, pain, and tissue loss

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How does CLTI alter vessels?

CLTI can lead to development of collateral flow, but the collateral flow is insufficient; also leads to turbulent flow

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How does CLTI compare to intermittent claudication?

Both cause pain, intermittent claudication resolves with rest while CLTI does not; CLTI = tissue loss

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What options exist for PAD treatment?

Medical treatment and Surgical + Medical combination

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What does medical treatment for PAD entail?

Walking therapy and CV risk factor modification

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Who receives medical treatment for PAD?

Asymptomatic patients only

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What are the surgical treatments for PAD?

Endartectomy, bypass graft, and endovascular patients; all in conjunction with medical therapy

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Who receives surgical therapy for PAD?

Surgical therapy is pursued in PAD patients with symptoms such as CLTI, claudication, etc.

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How does CV risk factor modification work?

Use CV Risk assessment to treat risk factors such as diabetes, hypertension, smoking, starting statins and antiplatelet therapy

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How does walking therapy improve intermittent claudication?

Increases pain free walking distance

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What is endartectomy?

Surgical removal of a plaque from an artery wall, used in symptomatic PAD

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What are emerging treatments for PAD?

Gene therapy with VEGF and Stem cell therapy with bone marrow; aims to grow blood vessels and improve blood flow

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What is Aortic Dissection?

Dissection of blood between and along the laminar planes of the media, leading to the formation of a blodo-filled false-lumen

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Where is the false lumen in Aortic Dissection found?

The false-lumen is found in the aortic wall, between the Intima and Media

How does the false lumen in Aortic Dissection affect perfusion?

Blood flow can be seriously occluded during systole as the flap of the false lumen expands and shunts blood into the anuerysmal area

What are the typical traits of someone affected by Aortic Dissection?

More common in males, higher in African Americans, predisposed by connective tissue disorders

What are the risk factors for Aortic Dissection?

Hypertension, connective tissue disorders, cocaine use

What are the possible causes of Aortic Dissection?

Medial degeneration and intimal thickening

What can cause medial degeneration, and what does this precipitate?

Deterioration of medial collagen and elastin as well as loss of smooth muscle cells can lead to Aortic Dissection

What can cause intimal thickening, and what does this precipitate?

Intimal thickening is caused by fibrosis, calcifications, and fatty acid depositions, which can lead to Aortic Dissection

How does Aortic Dissection present?

Severe pain + "ripping" sensation + malperfusion syndrome - leads to death if untreated

What are the signs of Malperfusion Syndrome?

Stroke, ischemia, hypotension

Which type of Aortic Dissection precipitates Cardiac Tamponade?

Type A Aortic Dissection leads to Cardiac Tamponade

What causes Type A Aortic Dissection?

Aortic Valve insufficiency, occlusion of coronary vessels, and rupture into the pericardium = surgical emergency

Which type of Aortic Dissection is a surgical emergency?

Type A, though complicated Type B is also treated with surgery

Which of of Aortic Dissection is treated medically?

Type B, but only if it's uncomplicated

How does Type B Aortic Dissection present?

Occluded branches of the Aorta = Intestinal ischemia, renal failure, leg ischemia

How can Type B Aortic Dissection obstruct branch vessels?

The neo-intimal flap can obstruct other vessels when the heart contracts

How can Aortic Dissection be visualized?

Intravascular Ultrasound

What can make Type B Aortic Dissection complicated?

Malperfusion, rupture, pseudoaneurysm

What are the surgical options for treatment of Type B Aortic Dissection?

Open thoracoabdomnial aortic replacment and TEVAR

How does TEVAR treat Aortic Dissection?

Thoracic Endovascular Aortic Repair uses a stent to cover the intimal tear and re-expand true lumen, pushing the flap out of the true lumen

What is an Aneurysm?

An aneurysm is a widening of the diameter of a vessel by at least 50%

What are the risk factors for Abdominal Aortic Aneurysm?

Genetics, Hypertension, Age, Gender, Atherosclerosis

What underlies the pathophysiology of Abdominal Aortic Aneurysm?

Inflammation caused by inflammatory cells result in the release of Matrix metalloproteinases that degrade Collagen and Elastin, leading to thinning of the Media

What cells produce MMP's and where are they found?

In the setting of AAA, MMP's are made by smooth muscle cells, fibroblasts, and inflammatory cells in the wall of the Aorta

Which MMP correlates with aneurysm size?

MMP-9, underlies pathophysiology of AAA

How are Aneurysm's described?

By location, size, shape, and etiology

What are possible shapes of aneurysms?

Fusiform or saccular

How does LaPlace's Law dictate aneurysm rupture?

LaPlace Law: T = P * R; As diameter and pressure rise, wall tension rises, increasing risk of rupture

Where can aortic aneurysms be found?

Infrarenal, Juxtarenal, Pararenal, Suprarenal

What is Marfan syndrome and how does it relate to AAA?

Marfan is a congenital Fibrillin-1 defect, predisposes AAA since there is less functional elastic tissue in the Media at birth

What is Ehlers-Danlos syndrome and how does it relate to AAA?

Ehlers-Danlos is a congenital procollagen defect, predisposes AAA since there is less elastic tissue in the media at birth

How can AAA be diagnosed?

Abdominal Aortic Aneurysm can be detected and diagnosed with CT scan and Ultrasonography

What is the most common form of AAA?

Degenerative Abdominal Aortic Aneurysm is the most common form

What are Mycotic aneurysms?

Aneurysms caused by primary or secondary infection with bacteria or fungi, such as Staph, Salmonella, or Strep

Which microorganisms cause Mycotic aneurysms?

Staph, Salmonella, Strep

What are inflammatory aneurysms?

Dense periaortic fibrosis due to inflammation from inflammatory cells

What cells cause inflammatory aneurysms?

Immune cells = lymphocytes, plasma cells, macrophages, giant cells

What arteries does an Infrarenal AAA obstruct?

None - the Infrarenal AAA is below the level of the renal arteries

What arteries does a Juxtarenal AAA obstruct?

None - the Juxtarenal AAA is directly underneath the renal arteries

What arteries does a Pararenal AAA obstruct?

Both renal arteries, but no arteries above the renal arteries

What arteries does a Suprarenal AAA obstruct?

Both renal arteries as well as arteries above them, such as the mesenteric artery

How does an AAA present?

May be asymptomatic, but can also include abdominal or back pain with Aortic rupture causing pain and hypotension

What size does an Aortic Abdominal Aorta need to be for repair?

Must be greater than 5.5cm in diameter

What are the treatment options for AAA?

Open repair and endovascular repair

How does open repair treat AAA?

The patient is surgically operated on to remove the portion of the Aorta with the aneurysm and replace that portion with a graft

How does endovascular repair treat AAA?

A variety of stents can be inserted via the saphenous vein customized to the patient's anatomy, with the only restriction being calcified arteries and concomitant aneurysms