Vascular Flashcards
DVT risk factors
using the mnemonic “THROMBOSIS”
(Guess as many as you can)
Travel HRT Recreational drugs Old (60+) Malignancy Blood d/o (factor V leiden, Antithrombin III def, etc) Obesity/Obstetrics/OCPs Surgery/Smoking Immobilization Sickness (CHF/MI, nephrotic syndrome, vasculitis)
List Virchow triad for DVT
Hypercoagulability
Endothelial damage
Venous stasis
Localized unilateral swelling, feeling of tightness or heaviness of lower extremity
Warmth, erythema
Progressive tenderness, dull pain
Fever
Homans sign: calf pain on dorsal flexion of the foot
diagnosis:
DVT
Acute onset of symptoms of: Dyspnea & tachypnea pleuritic chest pain Cough +/- hemoptysis Tachycardia & hypotension JVD \+/- DVT (unilaterally painful leg swelling)
Diagnosis:
pulmonary embolism
Features of massive PE:
- Syncope +/- pleural effusion
- Obstructive shock with circulatory collapse (saddle thrombus)
- Kussmaul’s sign (paradoxical rise in jugular venous pressure on inspiration)
Diagnostic approach for suspected lower-extremity DVT :
Check D-dimer first for low suspicion of DVT
Negative (< 500 ng/mL): DVT ruled out
Positive (≥ 500 ng/mL) → Duplex U/S
Pain, tenderness, induration, and erythema overlying a superficial vein, often with a palpable cord
diagnosis and next best step in management?
- Superficial thrombophlebitis
* palpable cord (the thrombosed vein) - get Compression ultrasound
Management of DVTs (2)
- LMWH (Enoxaparin)
- IVC Filter
For patients with contraindications for anticoagulation;
(active bleeding, recent major surgery, recent intracranial hemorrhage)
Causes of Pulmonary Embolism are
FATAL
Fat, Air, Thrombus, Amniotic fluid, and Less common (malignancy, bacteria)
Pathophysiologic response of the lung to PE arterial obstruction:
(Just read over)
Infarction and inflammation of lung →
pleuritic chest pain & hemoptysis
Impaired gas exchange →
ventilation-perfusion mismatch
Cardiac compromise →
Elevated pulmonary artery pressure → RV pressure ↑
Pulmonary vasoconstriction →
bronchospasm
ABG in pulmonary embolism shows:
- ↑/↓ SaO2
- ↑/↓ Alveolar-arterial gradient
- Respiratory (acidosis/alkalosis)
↓ SaO2
↑ Alveolar-arterial gradient
Respiratory alkalosis
Imaging to confirm PE
CT angiography
CT PA/ CT spiral
Treatment of Pulmonary Embolism
- Stabilize patient and provide supportive care*.
- Nonmassive PE: LMWH (AC) or IVC filter
Massive PE: Thrombolytics (tPA/alteplase) → embolectomy (unable to use tPA or unsuccessful)
*Supportive care
Hypotension or obstructive shock → IVFs
Respiratory support/ O2 supp
Cx of Pulmonary Embolism (2)
Right ventricular failure
Sudden cardiac death due to pulseless activity
Atelectasis
Pleural effusion
Pulmonary infarction
Recent history of orthopedic surgery Hypoxia Neurological symptoms Petechial rash thrombocytopenia
Diagnosis
Fat embolism
Recent history of surgery Barotrauma (mechanical ventilation) or Central venous catheter (insertion and removal) sudden hypoxia
Diagnosis
Air embolism
Intrapartum/post partum woman with acute onset of hypoxia; dyspnea hypotension; cardiac arrest DIC
Diagnosis
Amniotic Fluid Embolism
Tx: Emergency cesarean delivery & supportive
Clinical features:
Generalized or localized lower extremity pain, cramping, pruritus and/or swelling
Edema starting at ankle
Yellow-brown or red-brown skin pigmentation of the MEDIAL ankle or ulcers
varicose veins
Chronic Venous insufficiency
Lipodermatosclerosis: Localized chronic inflammation and fibrosis of skin and subcutaneous tissues of lower leg
Atrophie blanche: White, coin- to palm-sized atrophic plaques
If conservative management of chronic venous insufficiency fails or if diagnosis is uncertain what do next?
Duplex ultrasonography
Chronic venous insufficiency requires definitive treatment if there is recurrent:
Bleeding Ulcers
or
Superficial Thrombophlebitis
Technique: ___ therapies
vein ablation
Peripheral Venous Disease Ulcers
Most frequently occur just above the __
Shallow ulcer with __ borders
mildly painful
medial malleolus/ankle
irregular
(pt likely has a DVT)
Tx: elevation, compression stockings, Zinc-Copper wrap/paste
__ should be performed in any nonischemic wound that fails to improve after 3 months of treatment.
Biopsies
Peripheral Arterial Disease Ulcers:
- usually located over ___ or ___
- resting pain over ____
- claudication over calves
- low ABI (like ≤ __)
Risk factors:
-h/o atherosclerosis, smoking
dorsum of foot/ tips of toes
metatarsal heads
0.9
Stage I: asymptomatic
Stage II: pain on exertion
Stage III: at rest
-
Claudication is NOT a surgical disease.
Don’t use compression socks.
Treat underlying cause (smoking cessation, statin, glycemic control)
Exercise program (exercise > clopidogrel)
last line options:
Cilostazol (phosphodiesterase III inhibitor vasodilator)
Peripheral artery bypass surgery (revascularization)
Pseudoclaudication → presents like claudication, but at least one good peripheral pulse usually due to __
spinal stenosis (around L5-S1)
Resting ABI > 1.4 Interpretation:
Medial ____ with non-compressible vascular wall
calcific sclerosis
*Ankle-brachial index (ABI) =
systolic ankle BP: systolic brachial BP
CEAP classifications of venous insufficiency 0. No palpable/visible sxs on legs 1. 2. 3. edema 4. skin changes (sclerosis, eczema, pigmentation) 5. healed ulcers 6.
- Telangiectasia/ reticular veins
- Varicose veins
- Active ulcers
MCC of Subclavian steal syndrome
Atherosclerosis
Imaging for Subclavian steal syndrome
ultrasound
shows reversal of blood flow
Treatment for Subclavian steal syndrome in symptomatic patients
angioplasty/stenting
or
surgical revascularization
Clinical features: Limb ischemia (on exertion) Pain, paresthesia Pale, cool skin Weak, delayed radial pulse Disparity in BP > 15 mm Hg Dizziness, vertigo, syncope Diagnosis:
Subclavian steal syndrome
**Neurologic sxs (due to vertebrobasilar insufficiency)
Subclavian steal syndrome 2/2 ___ of the subclavian artery proximal to the origin of the vertebral artery → reversal of blood flow in ipsilateral vertebral artery
stenosis
Associated with polymyalgia rheumatica (PMR)
Giant cell temporal arteritis
elderly women
Immediate administration of ____ is crucial to lowering the risk of permanent vision loss in patients with giant cell arteritis.
high-dose glucocorticoids
Laboratory test ↑ in GCA
↑ ESR
Gold standard diagnostic for any patient
with suspected Giant cell temporal arteritis
Temporal artery biopsy
Complications of Giant cell temporal arteritis (3)
Permanent vision loss
Stroke
Aortic aneurysm and/or dissection
Carotid artery dissection is a rare complication of seemingly minor oropharyngeal trauma (a fall with object in mouth), or neck strain/manipulation/penetration (yoga, sports).
The dissection can cause thrombus formation, which occurs over hours to days and can extend into which 2 arteries?
MCA & ACA
Pt presents with
neck pain
“thunderclap” headache &
ischemic stroke like sxs: hemiparesis, facial droop, aphasia.
Diagnosis and next best step in management?
Carotid artery dissection
CT neck or MRA
Used to diagnose peripheral artery disease.
ankle-brachial index
Painful ulcer at at the tips of the toes (least perfused areas) or dorsum of foot. Cool, pale skin with dermal atrophy; and diminished pulses.
arterial ulcer
s/t PAD
____ used to diagnose venous insufficiency, stasis, or obstruction.
Duplex ultrasonography
Ulcer on the leg above the
Medial Malleolus
with edema, varicose veins, and stasis dermatitis (hairless, rough/smooth)
Venous ulcers
s/t Venous stasis
