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CVB by Minnie- 2024 Update > SM 137a - Peripheral Vascular Disease > Flashcards

SM 137a - Peripheral Vascular Disease Flashcards

1
Q

What congenital syndromes are associated with abdominal aortic aneurysm?

A

Marfan syndrome (Fibrilin-1 defect)

Type IV Ehlers-Danlos syndrome (Type III procollagen defect)

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2
Q

Describe the presentation of a patient with aortic dissection

A
  • Severe, excruciating pain in the anterior chest and back
  • Malperfusion syndrome
    • Stroke
    • Intestinal ischemia
    • Lower extremity ischemia
    • Paralysis
    • Cardiac tamponade (type A)
    • Coronary ostia compromise (type A)
    • Hypotension/shock
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3
Q

What is TEVAR?

What does it usually repair?

A

TEVAR = thoracic endovascular aortic repair

Typically repairs aortic dissection

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4
Q

What are the possible presentations of abdominal aortic aneurysm?

A

Asymptomatic

Abdominal or back pain

Distal emboli

Rupture (pain, hypotension, pulsatile mass)

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5
Q

What are the major risk factors for peripheral aterial disease (PAD)?

A

HASH-FAD

  • Hypertension
  • Age >65 years
  • Smoking
  • Hyperlipidemia
  • Family history
  • Atherosclerosis (known in another vasclar bed)
  • Diabetes
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6
Q

Males are ____ times as likely to have an abdominal aortic aneurysm than females

A

Males are 2-6 times as likely to have an abdominal aortic aneurysm than females

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7
Q

Type B aortic dissections are __________ to the left subclavian artery

A

Type B aortic dissections are Distal to the left subclavian artery

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8
Q

Patient population: 50+ years old, initial clinical presentation of peripheral arterial disease (PAD)

What fraction of these patients present with critical limb ischemia (aka CLTI)? (Box D)

A

1-3%

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9
Q

What complications of type B aortic dissection would create a need for emergency surgery?

A
  • Paraplegia
  • Renal failure
  • Renal vascular hypertension
  • Bowel gangrene
  • Leg ischemia
  • Intestinal ischemia
  • Rupture
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10
Q

As an aneurysm gets larger, the risk of it rupturing increases.

Which law explains this?

A

La Place’s Law

Increased diameter and pressure increase the wall pressure, thus increasing the risk of rupture

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11
Q

A patient with an abdominal aortic aneurysm has increased circulating levels of MMP-9

What do you recommend for treatment?

A

Increased levels of MMP-9 indicate a large, expanding aneurysm.

In this case, you will most likely want to repair the aneurysm surgically

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12
Q

____% of all abdominal aortic aneurisms are genetic

A

15-25% of all abdominal aortic aneurisms are genetic

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13
Q

Patient population: 50+ years old, initial clinical presentation of peripheral arterial disease (PAD)

Of the patients who do not have critical limb ischemia initially (97-99%), list the 5-year outcomes for limb mortality for:

Stable claudication (Box H):

Worsening claudication (Box I):

Critical limb ischemia (Box J):

A

Stable claudication (Box H): 70-80%

Worsening claudication (Box I): 10-20%

Critical limb ischemia (Box J): 5-10% - See 1 year outcomes for CLI

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14
Q

Patient population: 50+ years old, initial clinical presentation of peripheral arterial disease (PAD)

Of the patients who do not have critical limb ischemia initially (97-99%), list the 5-year outcomes for CV morbidity and mortality:

Non-fatal CV event (MI or stroke) (Box K):

Mortality (Box L):

A

Non-fatal CV event (MI or stroke) (Box K): 20%

Mortality (Box L): 10-15%
Note: 75% of these mortalities are from CV causes

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15
Q

What are the risk factors for initiation of an abdominal aortic aneurysm?

A

Genetics (connective tissue disorders)

Gender

Ethnicity

Age

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16
Q

People with peripheral arterial disease have a ___ fold increased risk of mortality

A

People with peripheral arterial disease have a 2-3 fold increased risk of mortality

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17
Q

Patient population: 50+ years old, initial clinical presentation of peripheral arterial disease (PAD)

Of the patients who present with critical limb ischemia (1-3%) list the 1-year outcomes for the following:

Alive with 2 limbs (Box E):

Amputation (Box F):

Mortality (Box G):

A

Alive with 2 limbs (Box E): 45%

Amputation (Box F): 30%

Mortality (Box G): 25%

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18
Q

What are the risk factors for progression of an abdominal aortic aneurysm?

A

Smoking

Hypertension

Atherosclerosis

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19
Q

What life-threatening sequale can arise from type A aortic dissection?

A

Aortic valve insufficiency

Occlusion of coronary vessels

Rupture into pericardium

20
Q

People between ____ and ____ years old are more likley to have a type A aortic dissection

People between ____ and ____ years old are more likley to have a type B aortic dissection

A

People between 50** and **60 years old are more likley to have a type A aortic dissection

People between 60 and 70 years old are more likley to have a type B aortic dissection

21
Q

People with peripheral aterial disease have a _____ fold increase in their chance of dying from coronary artery disease

A

People with peripheral aterial disease have a 4-5 fold increase in their chance of dying from coronary artery disease

22
Q

Type A aortic dissections are __________ to the left subclavian artery

A

Type A aortic dissections are proximal to the left subclavian artery

23
Q

What are the indications for surgical treatment of an abdominal aortic aneurysm?

A

The aneurysm should be repaired if it is…

  • Large (>5.5 cm)
  • Rapidly expanding (>0.5 cm/year)
  • Symptomatic
  • Ruptured - Emergency repair!
24
Q

What sources of MMPs are relevant to aortic aneurysm?

A
  • Vascular smooth muscle cells
  • Fibroblasts
  • Inflammatory cells
  • Endothelial cells surrounding the vasa vasorum
25
Q

What is EVAR?

What does it typically repair?

A

Endovascular AAA repair

(Abdominal aortic aneurysms)

26
Q

What are the 3 central themes that drive the pathophysiology of abdominal aortic aneurysms?

A
  1. Inflammation:
    Inflammatory cells release cytokines and activate MMPs
  2. Disruption of connective tissue architecture with loss of elastin:
    MMPs degrade collagen and elastin
  3. Medial thickening:
    Smooth muscle cells - increased apoptosis, decreased density, impaired proliferation
27
Q

How can circadian pattern paly a role in the pathophysiology of aortic dissection?

A

In the morning…

  • Increased sympathetic activity
    • Increased BP, HR
      • Increased shear forces
  • Increased platelet activation, fibrinogen, coagulation factor
    • Hyperoagulability + weakened arterial wall
      • Dissection
  • Decreased tissue plasminogen activator (tPA)
    • Hypofibrinolysis

All of the above lead to increased risk of aortic dissection

28
Q

Describe the pathophysiology of aortic dissection

A
  • Hypertenstion is usually implicated!
    • -> Medial degeneration
    • -> Intimal thickening
      • Fibrosis
      • Calcifications
      • Fatty acid deposition
    • Adventitial fibrosis

Also…

  • Inherited connective tissue disorders
  • Association with cocaine use
  • Circadian pattern (more sympathetic and platelet activity in the mornings)
29
Q

What is the mortality of untreated aortic dissection within…

6 hours:

24 hours:

1 week:

A

6 hours: 22.7%

24 hours: 50%

1 week: 68%

30
Q

How should type B aortic dissections be treated?

A
  • If complications are life threatening:
    • Emergency surgery
  • If complications are not life-threatening:
    • Use medical management
      • Decrease blood pressure
      • Decrease contractility
      • Decrease HR
      • Pain control
31
Q

Which two types of MMP are relevant to aortic aneurysm?

A
  • MMP-2
    • Substrates = collagen, gelatin, elastin
    • Levels increase in a small, stable aneurysm
  • MMP-9
    • Main substrate = elastin
    • Levels increase in large, expanding aneurysms
    • Tissue and circulating MMP-9 are proportional to aneurysm size
32
Q

Which type of aortic dissection is most life-threatening?

Why?

A

Type A aortic dissections are most life-threatening because they may involve the heart

  • Require emergency surgical treatment
  • May affect the aortic valve
    • -> Sudden valvular incompetence, death
  • May rupture into the pericardium
    • -> Death
33
Q

What are the 3 general types of peripheral arterial disease?

Which are classified as “chronic limb-threatening ischemia (CTLI),” aka “critical limb ischemia (CLI)”?

A
  1. Claudication: Pain with walking
  2. Rest pain: Pain in the feet at rest
  3. Tissue loss/ulceration/gangrene

2 and 3 are classified as CTLI/CLI

34
Q

Besides aorta, what are other vessels that may develop an aneurysm?

A
  • Popliteal (2nd most common location)
  • Subclavian
  • Femoral (99% occur in men)
  • Hand (usually caused by trauma)
35
Q

What are MMPs?

A

MMPs = Matrix metalloproteinases

  • Zinc-dependent enzymes
  • Secreted as zymogens (proenzymes)
    • Activated by inflammatory cytokines
  • Degrade collagen and elastin
36
Q

What is a mycotic aneurysm?

A

An aneurysm due to infection

37
Q

Patient population: 50+ years old, initial clinical presentation of peripheral arterial disease (PAD)

What fraction of these patients are are asymptomatic? (Box A)

A

A: 20-50%

38
Q

Patient population: 50+ years old, initial clinical presentation of peripheral arterial disease (PAD)

What fraction of these patients present with typical caudication? (Box C)

A

10-35%

39
Q

How should type A aortic dissections be treated?

A

Emergency surgery

40
Q

What defines an abominal aortic aneurysm?

A

Enlargement of the aortic diameter to 1.5x its normal diameter

(Typically >3cm total for the aorta)

41
Q

Patient population: 50+ years old, initial clinical presentation of peripheral arterial disease (PAD)

What fraction of these patients present with leg pain other than typical caudication or critical limb ischemia? (Box B)

A

B: 30-40%

42
Q

What type of genetic disorders predispose an individual to aortic dissection?

A

Connective tissue disorders; usually implicated if a young person has an aortic dissection

(ex: Marfan’s syndrome)

43
Q

What is the most common cause of peripheral arterial disease (PAD)?

A

Atherosclerosis

44
Q

What is an aortic dissection?

A

A tear in the edothelium of a major artery that causes blood to course through a small opening, into the media of a vessel

The layers then split over an extended length, creating a false lumen between the intima and the media

45
Q

What causes aneurysms to be pathologic?

A

If they rupture or thrombose/embolize

Rupture usually occurs in body cavities

Thrombosis/embolizm usually occurs in extremities

46
Q

List the possible etiologies of abdominal aortic aneurysm

A
  • Atherosclerotic (90%)
  • Infectious: Mycotic aneurysm
  • Inflammaotry
  • Congenital syndromes
  • Post-stenotic
  • Pseudoaneurysm
  • Congenital anatomy

CVB by Minnie- 2024 Update (43 decks)

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