Vascular 2 Flashcards
Gangrenous Ischemic colitis
severe acute ischemia of the large bowel resulting in ___
infarction
Nongangrenous Ischemic colitis
hypoperfusion of the large bowel
Management?
Conservative
Mostly transient and self-limiting
Acute mesenteric ischemia
acute inadequate blood flow to the ___ bowel (arterial or venous) that can result in bowel infarction
small
Chronic mesenteric ischemia
constant OR episodic hypoperfusion of the small intestine, usually due to
atherosclerosis
Causes of Ischemic colitis:
- Thromboembolism (a-fib, IE)
- Hypovolemia (dehydration, hemorrhage)
- Vasoconstrictive drugs
4.
Cardiovascular surgery (Aortic repairs & cardiac bypass)
Sites at High risk for compromise in Ischemic colitis (2)
because they are “watershed areas”
Splenic flexure
Rectosigmoid junction
Clinical features of Ischemic colitis:
- Hyperactive phase
- Sudden onset of ___ abdominal pain
- ____ stools - Shock phase (rare)
- _____
Crampy
Loose, Bloody
Peritonitis
(rebound/guarding)
In severe ischemic colitis labs can show:
↑ ___, ___, Creatinine Kinase
Leukocytosis
Lactate
LDH
Imaging for suspected Ischemic colitis
First line:
Confirmatory:
KUB: abdominal x-ray
(air-filled, distended bowel)
CT scan (wall thickening, air in intestine walls)
Thumbprint sign: edematous thickening of the mucosa causes indentations in the large bowel wall
Mild-Moderate Ischemic colitis
- No specific laboratory finding
- Procedure of choice in moderate cases =
Colonoscopy ( edema, cyanosis, +/- ulceration)
Management of mild-moderate sxs:
Conservative:
IVF, NPO, +/- NGT
Antiplatelet +/- Anticoagulation therapy
Definitive management of Ischemic colitis with signs of sepsis and peritoneal irritation?
Ex-lap
postprandial mismatch between splanchnic blood flow and intestinal metabolic demand → postprandial pain
Diagnosis:
Chronic Mesenteric Ischemia
Clinical features Crampy abdominal/intestinal angina Recurrent, dull, postprandial epigastric pain ~within the first hour after eating a fear of eating → weight loss Diagnosis:
Chronic Mesenteric Ischemia
Chronic Mesenteric Ischemia
Imaging:
Treatment:
CT-Angiography
Frequent, small low-fat meals Revascularization surgery (if severe)
Acute Mesenteric Ischemia typically caused by what
Atrial Fibrillation → arterial embolism
SMA (∼ 90% of cases)
A patient with ____ typically presents with severe abdominal pain (usually periumbilical) fever, +/-bloody diarrhea, leukocytosis, ↑ Lactate.
Typically h/o a-fib
Acute Mesenteric Ischemia
A patient with ____ typically has a known cardiovascular or peripheral vascular disease and/or symptoms of chronic mesenteric ischemia in addition to the acute symptoms.
Acute arterial thrombosis
confirmatory test for Acute Mesenteric Ischemia
CT-Angiography
- wall thickening
- distended bowel with black flecks and stripes aka Pneumatosis Intestinalis (suggests transmural ischemia or infarction)
Treatment of Acute Mesenteric Ischemia
1. Bowel rest +
Definitive management:
- hemodynamically unstable: ___
- hemodynamically stable patients w/o signs of advanced ischemia: ___
Long-term measures:
Statin therapy
____ therapy
IVFs, NGT, NPO + ABxs
- Ex-Lap for (unstable, peritonitic, or septic)
- Embolectomy mechanically
- Bypass of artery - Endovascular revascularization (stable)
- Angioplasty + Stenting
- Catheter-based Heparin (thrombolytics) or mechanical thrombectomy
Anticoagulation (for long-term)
Bilaterally absent femoral, popliteal, and ankle pulses
Pain in both legs and the buttocks
Erectile dysfunction
Leriche syndrome (aortoiliac occlusive disease)
Leriche syndrome (aortoiliac occlusive disease) sxs (3)
bilateral absent LE pulses
pain in legs/butt
erectile dysfunction
Acute limb ischemia
Best initial test: ____
Confirmatory test: ____
Doppler U/S (arterial & venous)
Angiography (CTA, MRA, DSA*)
*Digital subtraction angiography
Treatment of Acute limb ischemia due to thromboembolism:
IV heparin bolus followed by continuous infusion
Treatment of Acute limb ischemia s/p anticoagulation:
Angiography → Revascularization
Treatment of Acute limb ischemia s/p HEPARIN ANTICOAGULATION :
- Threatened limb
Emergent (w/in 6hr) ____ - Non-viable limb
Limb amputation
Revascularization via
Catheter-directed Thrombolysis
*(or percutaneous Thromboembolectomy)
Contraindication to cardiac catheterization
Acute renal failure
Risk factors for Thoracic aortic aneurysm:
[PMH]
Smoking
Trauma
[Congenital]
[s/t obliterative endarteritis in vasa vasorum]
Connective tissue diseases (Marfan syndrome, Ehlers-Danlos syndrome)
Arterial HTN
Bicuspid aortic valve (Turner syndrome)
Tertiary syphilis
Descending thoracic aortic aneurysm: typically 2/2 ____
atherosclerosis
Pt presents with raspy voice and feeling like food gets stuck in his chest causing pressure & now back pain.
Suspected Diagnosis?
Thoracic aortic aneurysm
+/- sxs of mediastinal compression/obstruction:
- Difficulty swallowing (esophagus)
- Upper venous congestion (SVC syndrome)
- Hoarseness (recurrent laryngeal nerve)
Best confirmatory test for Thoracic aortic aneurysm
CT angiography chest
initial CXR may show widened mediastinum
Conservative management for Thoracic aortic aneurysm (3)
Antihypertensives
Smoking cessation
Statins
Clinical features of ruptured TAA:
__ rupture → Severe chest pain
__ rupture →Possible loss of consciousness
Contained
Free
Procedure Indications:
Degenerative or traumatic descending aortic aneurysms
Thoracic endovascular aneurysm repair (TEVAR)
Type of surgery for:
- Ascending Thoracic Aortic Aneurysm or Aortic Arch Aneurysm:
- Descending Thoracic Aortic Aneurysm or Abdominal Aortic Aneurysm:
- Open surgical repair (OSR)
2. Thoracic endovascular aneurysm repair (TEVAR)
Complications of Thoracic aortic aneurysm:
- Left-sided ____
- ____ s/t bleeding into the mediastinum
- Hemothorax
- Cardiac Tamponade
( s/t bleeding into the mediastinum)
most important risk factor in Abdominal Aortic Aneurysms
Smoking
Lower back pain
Pulsatile abdominal mass
Bruit on auscultation
Diagnosis:
Abdominal Aortic Aneurysm
Infrarenal Aortic Aneurysm
Best initial and confirmatory test for:
- Abdominal Aortic Aneurysm
- Thoracic Aortic Aneurysm
- Abdominal ultrasound
(Unless pt Obese → CTA or MRA) - CXR → CTA chest
Indications for repair of Abdominal Aortic Aneurysms:
Diameter: ≥ __ cm
Expansion rate: ≥ _ cm/year
Symptomatic aneurysm
Has ruptured
- 5
1. 0
Indications for repair of Thoracic Aortic Aneurysms
Diameter
AScending aneurysm ≥ __ cm
DEscending aneurysm ≥ __cm
- 5
6. 5
How do you surveillance an un-repaired AAA of
5.0–5.4 cm
[imaging] q [timing]
Ultrasound every 6 months
Pt presents with Sudden onset of severe, tearing back & abdominal pain with radiation to the flank, buttocks, legs, or groin.
Vitals show tachycardia & 90/40 (narrowed PP)
(Hypovolemic shock)
Painful pulsatile mass on abdominal exam.
Diagnosis?
Ruptured AAA
Unstable patients with suspected Abdominal aortic aneurysm rupture management:
Surgery (ideally within 90 minutes):
EVAR or OSR
(diagnosis is clinical)
stable patients with suspected Abdominal aortic aneurysm rupture management:
CTA Thorax, Abdomen, and Pelvis
(for surgical planning)
(Black crescent within mural thrombus + extravasation of contrast)
1 x Screening for AAA with abdominal U/S
In men aged __ years with any h/o smoking
65–75
Risk Factors for Aortic Dissection: \_\_\_ (most common risk factor) Trauma ( \_\_\_\_ injury) Vasculitis (syphilis) \_\_\_\_ use [congenital] Connective tissue disease (Marfan syndrome, Ehlers-Danlos syndrome)
Hypertension
deceleration injury
Amphetamines and cocaine
Bicuspid aortic valve (Turner syndrome)
Clinical features:
- Sudden and severe tearing/ripping pain in anterior chest (ascending) or back (descending)
- Interscapular or retrosternal pain
- Hypertension
- Asymmetrical blood pressure and pulse readings between limbs
- Syncope, diaphoresis, confusion
Diagnosis
Aortic Dissection
Normal ___ findings do not rule out aortic dissection.
CXR
If clinical suspicion for acute aortic dissection persists, perform a CT C/A/P
In STABLE pt with suspected aortic dissection what imaging is best:
CTA
chest, abdomen, and pelvis
In UN-stable pt with suspected aortic dissection what imaging is best:
(Or if pt has renal insufficiency or contrast allergy)
Transesophageal echocardiography (TEE)
CXR if TEE not available
Classic CXR finding of aortic dissection:
Widened mediastinum
initial test, but is negative get CTA
Treatment
Stanford A dissection: ____
Stanford B dissection: ____
Ascending = surgical emergency!
Conservative = Anti-hypertensives, Telemetry
unless complications occur
In patient with suspected aortic dissection what management do you want to start first then second?
FIRST: Beta Blocker (BP control prevents progression)
Second: VASODILATOR
(IV sodium nitroprusside)
*Avoid thrombolytic therapy & Inotropes