SM_248a: Limb Vasculature: Clinical Cases

Question 1

Axillary artery is called the ____ above teres major and the ____ below teres major

Answer 1

Axillary artery is called the axillary artery above teres major and the brachial artery below teres major

Question 2

Describe the Roos test

Answer 2

Roos test

• Used to test for thoracic outlet syndrome: sensitive, not specific
• Open and close fists for minimum of two minutes
• Encourage patient to report any symptoms: pain, fatigue, numbness, tingling

Question 3

Describe thoracic outlet syndrome

Answer 3

Thoracic outlet syndrome

• Can affect structures such as brachial plexus, subclavian artery, and subclavian vein
• Compression of the area causes a constellation of distinct symptoms: upper extremity pallor, parasthesia, weakness, muscle atrophy, and pain
• Compression of nerve roots most often occurs within the interscalene triangle but can also occur in the subcoracoid space as nerve roots transverse beneath the pectoralis minor tendon
• Classification: neurogenic, venous, or arterial

(testing via imaging and EMG, treatment is conservative)

Question 4

____, ____, ____, ____, ____, and ____ can cause thoracic outlet syndrome

Answer 4

Trauma, repetitive motions, anatomic variations, tumors / enlarged lymph nodes, injury to neck or back, and poor posture can cause thoracic outlet syndrome

Question 5

____ is the most common type of thoracic outlet syndrome

Answer 5

Neurogenic thoracic outlet syndrome is the most common type of thoracic outlet syndrome

Question 6

Describe neurogenic thoracic outlet syndrome

Answer 6

Neurogenic thoracic outlet syndrome

• Most often bilateral and with normal neurologic exam
• F > M
• Teens to 60s
• 95% of thoracic outlet syndrome cases
• Symptoms: upper limb parasthesias, trapezius pain, neck pain, shoulder/arm pain, supraclavicular pain, occipital headache, chest pain, parasthesias in fingers

Question 7

Neurogenic thoracic outlet is most often ___ and with ___ neurologic exam

Answer 7

Neurogenic thoracic outlet is most often bilateral and with normal neurologic exam

Question 8

Describe venous thoracic outlet syndrome

Answer 8

Venous thoracic outlet syndrome

• Most often unilateral affecting dominant upper extremity
• Subclavian vein compression commonly within costoclavicular space - bllod flow stagnation and effort thrombosis
• Paget-Schroetter disease (effort thrombosis): axillary or subclavian venous thrombosis following strenuous repeated activity with the arms
• M>F
• 15-45 years old, physically active
• 3-5% of cases

Question 9

In venous thoracic outlet syndrome, presentation of the upper extremity involves ___, ___, ___, and ___

Answer 9

In venous thoracic outlet syndrome, presentation of the upper extremity involves swelling, cyanosis, heaviness, and pain

• Associated with unilateral Raynaud-like symptoms, pulmonary embolism

Question 10

Venous thoracic outlet syndrome is associated with ____ and ____

Answer 10

Venous thoracic outlet syndrome is associated with Raynaud-like symptoms and pulmonary embolism

Question 11

Describe arterial thoracic outlet syndrome

Answer 11

Arterial thoracic outlet syndrome

• Predominantly unilateral
• Subclavian artery compression within costoclavicular space may be caused by anomalous first rib
• May be seen in physically active patients - arterial entrapment occurs at level of pectoralis minor tendon and humeral head
• Arterial compression -> intimal damage, turbulent blood flow, vessel dilation
• Arterial thrombosis and distal embolization -> distal upper extremity ischemia
• Clinical features: primarily vascular, secondary neurologic abnormalities as sequelae
• M = F, young adults
• 1-2% (rarest)

Question 12

Describe DVT presentation

Answer 12

DVT presentation

• Pain (typically throbbing)
• Leg swelling / edema
• Redness / erythema
• Increased warmth
• Pain comes on while walking or bearing weight
• Some patients are asymptomatic and DVT is incidentally found

Question 13

DVT most commonly occurs in the ____

Answer 13

DVT most commonly occurs in the distal veins

Question 14

DVT is usually treated with ____

Answer 14

DVT is usually treated with anticoagulation

Question 15

Describe Baker’s (popliteal) cyst

Answer 15

Baker’s (popliteal) cyst

• Fluid-filled distention of a pre-existing bursa in the medial popliteal fossa: most commonly gastrocnemio-semimembranosus bursa
• Bursa communicates through an opening in the joint capsule posterior to the medial femoral condule
• Opening creates a valve-like mechanism in the presence of effusion that contributes to formation

Question 16

Describe presentation and testing of Baker’s cyst

Answer 16

Baker’s cyst

• Often associated with othe intra-articular pathologies and inflammatory conditions, can be asymptomatic, can rupture w/o knee previous knee pain, usually in older individual, associated with mild to moderate leg edema ± bruising, difficult to palpate
• Best seen by MRI but may be seen on ultrasound or venous Doppler

Question 17

Ruptured baker cyst can compress ____ and ____ and can present similar to a ____

Answer 17

Ruptured baker cyst can compress popliteal artery/vein with subsequent ischemia or thrombosis and the tibia or peroneal nerve and can present similar to a DVT

Question 18

Popliteal fossa borders are the ____, ____, and ____

Answer 18

Popliteal fossa borders are the biceps femoris tendon superolaterally, semimembranosus muscle and semitendinosus tendon superomedially, and medial and lateral heads of the gastrocnemius muscle inferomedially and laterally

Question 19

Describe popliteal artery entrapment

Answer 19

Popliteal artery entrapment

• Incidence of up to 3.5%
• Bilateral in < 50%
• Young and athletic with intermittent calf or foot claudication ± coldness, numbness, or parasthesias
• Pain at rest not common
• Anatomic cause: anatomic anomaly
• Functional cause: muscle hypertrophy with normal anatomy
• Physical exam often normal

Question 20

Ankle-brachial index is ___ and is abnormal if ___

Answer 20

Ankle-brachial index is ratio of blood pressure at ankle to blood pressure at arm and is abnormal if ≤ 0.9

(used for popliteal artery entrapment)

Question 21

Describe testing and treatment for popliteal artery entrapment

Answer 21

Popliteal artery entrapment

• Test: ankle-brachial index, ultrasound for Doppler, MRI/MRA, angiography
• Treatment: surgery if pervasive symptoms

Question 22

Atherosclerosis is ____ and commonly affects ____, ____, ____, and ____

Answer 22

Atherosclerosis is plaque buildup inside artery and commonly affects CIA, SFA, popliteal artery, and tibial arteries

Question 23

Describe peripheral artery disease

Answer 23

Peripheral artery disease

• Most commonly due to atherosclerosis
• Many patients asymptomatic but some with intermittent claudication
• Most patients have ischemic heart disease
• Few progress to critical limb ischemia
• Can present similarly to other painful conditions
• Can coexist with peripheral polyneuropathy
• Treatment is modifying risk factors and exercise

Question 24

_____ is the physican exam finding most specific for peripheral artery disease and _____ index should always be done in cases of suspected peripheral artery disease

Answer 24

Lack of palpable pulse is the physican exam finding most specific for peripheral artery disease and ankle-brachial pressure index should always be done in cases of suspected peripheral artery disease

Question 25

Describe systemic lupus erythematosus

Answer 25

Systematic lupus erythematosus

• Associated with atherosclerosis and cardiovascular disease in young women without risk factors
• Strong risk factor for CVD
• Presence of longstanding systemic inflammation due to persistently activated SLE could contribute to plaque formation and disruption and cause direct vascular damage
• Patients have high prevalence of traditional CVD risk factors
• Affects lower limb