Vascular Flashcards
Presentations of AAA
Incidental
Pain (abdo, flank, chest, thigh, groin or scrotum)
syncope
Hemorrhagic shock
Abdominal mass / fullness
Ureteral Colic
Upper or lower GI bleed - fisutla
High output CHF - Aortovenous or aortocaval fistula
Physical Findings of AAA
Pulsatile mass
Triad: pain, mass, hypotension
Distended, large, tender, guarded abdo (blood-induced ileus)
More rare: Bruits, most have normal femorals,
VTE possible - blue toe syndrome, acute lower extremity occlusions
Aneurysm vs Pseudoaneurysm Def’n
Aneurysm: Dilation of all three layers (intima, media and adeventitia)
Pseduo: Arterial wall defect that is in communication but can be walled off from true lumen
AAA Common Misdiagnoses
mechanical LBP
renal colic
acute MI
prevorated viscous
Acute abdomen (pancreatitis, diverticulitis, cholecystitis, appendicitis, obstruction)
Intestinal ischemia
3 complications of AAA repair
Infection
Aortoenteric fistula
Pseudoaneurysm with anastomotic leak
Common complications of endovascular AAA repair
Femoral pseudoaneurysm
Infection
Ischemia - spinal cord, gut, renal, extremity
AEF
Chylothorax
Leak
AAA - size criteria
< 3 cm normal
> 5 cm - risk of rupture.
AAA Management
Surgical Repair is ruptured.
MOVIE - At least 6U immediately available
OR stat
Mortality with rupture is 30-40%
Etiologies of HTN
Primary - Idopathic / Essential
Secondary:
*Endo:
- Hyperaldo / Cushings
- Hyperthyroid
- OCP Use
- Pheochromocytoma
*Pulmonary:
- OSA
*Renal:
- RAS
- Nephrotic / Nephritic
- DM nephropathy
- PCKD
*Toxic / Metabolic:
- Sympathomimetic
- EtOH use chronic
*Vascular
- Atherosclerosis
- Coarctation of Aorta
Aortic Dissection Risk Factors
Family Hx (3x)
Bicuspid Valve
Connective tissue
Male
Hx of CV Surgery
Classifications for AD
DeBakey
- Type I - Arises in ascending and includes descending
- Type II - Ascending only
- Type III - Descending only
Standford
- Type A - Ascending
- Type B - Descending (Below)
* Below the L subclavian
AD Presentation and Signs
Tearing pain (Thunderclap ~ 50%)
Radiation to back
New neuro deficit
Migratory (only 17%)
Evolving symptoms
Signs:
New aortic regurg
Pulse deficit
BP discrepancy
Signs of tamponade (Beck’s: Hypotension, distended neck veins, muffled heart sounds)
Neuro findings - stroke, peripheral deficits
Widened mediastinum
Inferior or RV/posterior MI (Dissection in RCA)
Aortic dissection Investigations
Trop
D-Dimer
CXR
ECG
Advanced imaging
CT-A Diagnostic Gold standard
TEE good sensitivity
TTE / POCUS less sensitive
CXR Findings of AD
Wide mediastinum
Loss of PA window
Loss of Aortic knuckle
Esophagus displaced to R.
Trachea to R
L mainstem down
Pleural effusion
Apical Cap
NG deviated to R
Role of D-Dimer in Aortic Dissection
94-99% sensitive
False negative: false lumen, intramural hematoma, chronic, young age
96% sensitive with cut-off of 500
Aortic Dissection Pathway for Testing
High-risk physical exam findings
Risk factors
High-risk pain features
AAS most likely dx
Low - no testing
Moderate - D-Dimer
High Risk - CT-A
Practical Steps:
1. Get hx to rule out high risk features
2. Examine for new murmurs, neurodeficits, pulse deficits
3. Check BP for hypotension
4. POCUS
5. XR
6. ECG and Trop
STEMI - angio
Stroke - CT/CTA
Calculate risk based on findings.
Aortic Dissection Treatment
Pain - Fentanyl
HR - Labetalol or Esmolol. If asthma can give Diltiazem or Verapamil
Then Nitroprusside or IV Ace inhibitor (Enaliprilat)
Type A: emergent surgery. med mgmt in ED. May need pericardiocentesis.
Type B: Medical management in ICU. Vasc Sx Consultation.
5 Causes of Hypotension in AD
Pseudo hypotension.
Tamponade / Pericardial Effusion
STEMI
Aortic regurg
Aortic Wall Rupture (no chest tube)
AAA leaks - 5 types
1 - At waist or ankles
2 - Branch vessel
3 - Leakage at anastomosis between stent components
4 - Leakage through graft material
5 - NYD
Differential for DVT
Venous insuffiency
Baker’s Cyst / Rupture
Cellulitis
SVT
Vasculitis
Fracture
Lymphedema
Hematoma
Calf Strain
Causes of elevated D-Dimer
Trauma
Sepsis
VTE
Aging
Recent Sx
Stroke
MI
Bed Rest / casting
Malignancy
Pregnancy
Wells’ Criteria DVT
PE:
Pitting edema to symptomatic leg only
Tender to palpation
Entire leg swollen
Superficial non-varicose
Calf Swelling > 3 cm
Hx:
Previous DVT
Recent Sx / Bedridden
Active cancer
Plaster Immobilization
Risk Factors for PE
Inherited thrombophilia
Cancer
Pregnancy
Prior DVT/PE
Surgery or trauma
Dsypnea
Hemoptysis
Pulse > 100
O2 < 95%
Unilateral limb swelling
Types of PE
Low risk - labs and vitals normal
Non-massive - BP > 90, elevated trop/dimer, RV dysfunction, SpO2 < 94%
Submassive - Moderate distress, new RBBB, Sp)2 < 90%
Massive - Hypotension < 90 sBP for > 15 minutes, distress, cardiac arrest
ECG and CXR Findings of PE
New RBBB, A. Fib, Sinus tach, Symmetric TWI in V1-V4, S1Q3T3
Unilateral basilar atelectasis, Hampton’s Hump, Westmark sign (decreased BV on affected side)
Wells PE
Hx: Past PE/DVT, recent Sx or immobilization, active Ca
Physical: Signs of DVT, hemoptysis, HR > 100
Gestalt: Most likely Dx
PERC
Cannot rule rule out if:
Age > 50
OCP
HR > 100
O2 sat < 95% on room air
Hemoptysis
Unilateral leg
Hx of DVT/PE
Recent Trauma / Sx
What are Phlegmasia Cerulea Dolens and alba dolens
Blue leg due to massive iliofemoral DVT. (Alba - white)
Year’s Criteria
Signs of DVT
Hemoptysis
PE most likely
If none of above D-Dimer < 1000 Rule out
If any of signs above - D-Dimer 500
If signs of DVT - US.
- If normal Dimer < 500
- If abnormal - Treat
Differential for peripheral arterial insufficiency
Venous insufficieny
Neuropathic ulcers
Nocturnal muscle cramps
Aorto-occlusive disease
Vasculitis
Spinal stenosis
3 Disorders of Abnormal Vasomotor Response
Reynauds Disease (Phenomenon when 2nd disease present)
Benign Livedo Reticularis
Acrocyanosis
Primary Erythromelalgia
Reynaud’s Disease Characteristics
Cold or emotional upset
Bilateral symptoms
No / minimal tissue loss
No systemic disease for Reynaud’s Phenomenon
2 years of Symptoms
Classics - White - Purple - Red
Tx: CCB for symptomatic relief
3 Types of Visceral Aneurysms
Splenic Artery: (most common in young pregnant females)
- Should be coiled
- 70% mortality if rupture
Hepatic Artery: Stem from atherscerosis, infection, post trauma, polyarteritis
- Men > 60
- Usually asymptomatic - need to be treated when found
SMA: 60% by non-hemolytic strep from infective endocarditis
- Usually < 50, IV drug users
- Upper abdo angina
3 Types of Thoracic Outlet Syndrome
1) Compression of brachial plexus
2) “ “ subclavian artery
3) “ “ “ vein
Or all of the above
95% with compression of plexus
Types of Infective Aneurysm
Mycotic - Endocarditis, strep usually or staph
Atherosclerotic
Pre-existing aneurysm
Post-traumatic
