Summary of Essentials - Ch. 55-58 (Vascular)

Question 1

DDx - amaurosis fugax?

Answer 1

Carotid embolus, central retinal artery occlusion, giant cell arteritis, retinal vein occlusion, retinal detachment, papilledema, optic neuritis

Question 2

Presentation - amaurosis fugax (ipsilateral), arm/leg weakness and numbness (contralateral), +/- aphasia, emobli to the retina on fundoscopy, carotid bruit (specific, not sensitive)

Answer 2

Carotid stenosis

Question 3

True or false - dizziness, syncope, headaches are not typical carotid symptoms

Answer 3

True

Question 4

Work-up of suspected carotid artery disease?

Answer 4

Carotid duplex to determine % ICA stenosis
Confirmatory imaging (CTA or MRA)

Question 5

Who should get a carotid end arterectomy?

Answer 5

Greatest benefit for symptomatic 70-99% stenosis
Less benefit for symptomatic 50-69%/asymptomatic 60-99%
NO benefit for <50%

Question 6

Who should get carotid stenting?

Answer 6

Symptomatic ICA stenosis with high cardiac risk or hostile neck (previous radiation/surgery)

Question 7

Presentation - calf/thigh/buttock pain walking, relieved by rest, reproducible at same distance, absent pulses, muscle atrophy, hair los, dry/atrophic skin, toe ulcers, thickened toenails

Answer 7

Peripheral artery disease

Question 8

Dx PAD?

Answer 8

H&P supplemented by ABI with Doppler

CT/MRA only if intervention is planned

Question 9

Management of PAD?

Answer 9

Conservative for claudication: smoking cessation, walking program, statin, aspirin
Best drug: cilostazol (alternative - pentoxifylline, less effective)
Ischemia rest pain or tissue loss: interventional (angioplasty/stenting for short occlusion/stenosis), endarterectomy, surgical bypass (long occlusion)

Question 10

Presentation - PAD + arm claudication and dizziness?

Answer 10

Subclavian steal syndrome

Question 11

Presentation - buttock claudication, absent femoral pulses, impotence

Answer 11

Leriche syndrome

Question 12

Presentation - young male smokers with distal artery and vein occlusions

Answer 12

Buerger’s disease

Question 13

When might ABI be falsely normal?

Answer 13

DM with medial calcinosis

Question 14

Presentation - elderly male smokers, acute abdominal pain radiating to the back or flank, hypotension, tachycardia, pallor, diaphoresis,

Answer 14

AAA

Question 15

Dx AAA?

Answer 15

Unstable - H&P
Stable - CT angio
Abdominal U/S can diagnose presence/size, not useful for rupture

Question 16

Who should be screened for AAA?

Answer 16

Men aged 65-75 with any smoking history or start at 60 if 1st degree relative with AAA; patients with femoral or popliteal artery aneurysm; aortic diameter >3 cm

Question 17

Management of ruptured AAA?

Answer 17

IV access, limit fluids
Permissive hypotension (as low as 70)
Avoid intubation until in the OR
If stable - CT to confirm and determine if EVAR
If unstable - open repair (consider U/S if dx in question)

Question 18

Management of non-ruptured AAA?

Answer 18

<5.5 cm - observe

>5.5 cm - open or EVAR

Question 19

Define acute leg ischemia

Answer 19

Decreased limb perfusion of <2 weeks duration

Question 20

What is the sine qua non of acute limb ischemia?

Answer 20

Pulselesness

Question 21

What suggests a thrombotic cause of acute limb ischemia?

Answer 21

Exam or contralateral non-ischemic limb that may show signs of chronic PAD

Question 22

What suggests an embolic cause of acute limb ischemia?

Answer 22

AFib, atrial flutter, valvular disease, heart failure

Question 23

Irreversible damage of skeletal muscle tissue in acute limb ischemia begins at ___ and may be completed at ___.

Answer 23

3 hours; 6 hours

Question 24

Dx acute limb ischemia?

Answer 24

Doppler (fast)
CT angio (more information)

Question 25

Management of acute limb ischemia?

Answer 25

Immediate IV heparin and IV fluids
Place limb in dependent position
Definitive Rx - catheter-directed thrombolysis or open surgery (thrombolysis takes 24-48 hours to complete, only use if stage I or IIa - sensory deficit only); revascularization for stage IIb (sensory and motor deficit)
Amputation for stage III (complete anesthesia and paralysis)