Vascular Flashcards
RAS intervention
Pulmonary edema/unexplained HF (class I) or refractory HTN - with no other identifiable reason - ok to intervene on >70% stenosis in renal artery
ABI
right ABI=(higher right ankle pressure)/Higher arm pressure 1-1.29=normal >=1.3=non-compressible .9-.99=borderline 0.41-0.89=mild to mod <=0.4=severe
Screening for PAD
- Excertion leg symptoms
- Age >65yo
- Age >50yo with h/o tobacco use OR DM
- Non-healing LE wounds
Screening for AAA
- Men >60yo with 1st deg relative with AAA
2. Men >65-75yo who EVER smoked
Pulmonary embolism Clinical presentation
Chest pain, dypnea, hypoxia, sinus tach in setting of normal chest xray and clear lungs
Acute ischemic stroke - lytics
Can treat 3-4.5 hrs... Always rTPA (never streptokinase) 0.9mg/kg max 90mg Contraindications: 1) Recent stroke/TIA w/in 3 months 2) BP>185/110 3) Active internal bleeding 4) heparin w/in 48hrs 5) Plt <100 6)Current NOAC use 7) INR>1.7 8) FSG <50 9) Multi-lobar infarction
Dx of PAD
If normal resting ABI
then need exercise ABI (treadmill)
TBI if ABI is non-compressible (ie >1.3)
Sx PAD therapy
Supervised excercise - improved 6MWT
Cilostozol CONTAINDIC with HF
PENTOXYphline ok but not great
RAS - indication for intervention (IIa)
previously well controlled HTN now escaped
recurrent CHF exacerbations
Flash pulm edema out of proportion to LV systolic dysfucntion or burden of CAD
unexplained discrepancy in kidney size
unexplained dec’d kidney fxn
early (before 30) or late (after 55) onset HTN
U/A
RAS pathophys
kidney 1 RAS->kidney sense lower vol, kidney 2 secretes renin (angiotensin->aldosterone) - sodium retention->inc’d BP
Burger’s dz (thromboangiitis obliterans)
non-atherosclerotic dz of small and med sized upper and LE vessels - multiple limbs, corkscrew collaterals
YOUNG MALE SMOKER
multiple limbs, ischemic ulcers, normal A1c (diabetes excludes burgers), abn of ONLY distal vessels (prox sparing)
Tx: tobacco cessation
Giant Cell arteritis
If clinically suspected treat with steroids right away (older adult with inflammatory illness and headaches, scalp tenderness jaw claudication, blindness)
1) >50 years of age, 2) recent onset of localized headaches, 3) temporal artery tenderness or pulse attenuation, 4) erythrocyte sedimentation rate >50 mm/h, and 5) arterial biopsy showing necrotizing vasculitis. W>M, >55yo
MRA to check etiology (mural enhancement of aortic arch
Takayasu arterities
Young adult with subacute inflamm illness and h/a and interarm BP diff
Massive PE
Hypotension
Saddle PE
RV failure -> lytics - if contraindication then catheter directed thrombolysis
PE Risk Stratification
RV dilation/hypokinesis TR Pulm HTN with tricuspid jet >2.6m/s RV>0.9 LV diameter decreased TAPSE <17mm Dilation and loss of collapse of IVC with inpiration D-septum (systolic)
Symptomatic Carotid stenosis
benefit of carotid endarectomy best within 2 weeks of symptomatic carotid stenosis episode (ie TIA/CVA) >70% STENOSIS
Chronic mesenteric ischemia
Weight loss (post prandial pain) Abd bruit food avoidance Indication for intervetnion -wt loss Tx: Lifestyle mod smoking cessation lipid tx glucose control BP control
Carotid stenosis guidelines
Normal - <125cm/s
<50% - <125cm/s, ICA/CCA <2.0, ICA EDV <40
50-69% - 125-230cm/s, ICA/CCA 2.0-4.0, ICA EDV 40-100
>70% - >230cm/s, ICA/CCA >4.0 PSV ratio, ICA EDV>100
Near occlusion - high/low/undetectable PSV, variable ICA/CCA ratio, variable ICA EDV
Renal artery Stenosis (atherosclerotic
Ostial (contiguous with aorta)
a/w dec’d renal fxn
Fibromusclar dysplasia RAS
younger/middle aged women with HTN middle or distal segment no impaired renal fxn abdominal bruit inc'd velocity on doppler beaded appearance POBA without stenting best therapy for HTN
Large artery vasculitis
periarterial enhancement on CT/MRI
Cryptogenic stroke with PFO and carotid dz
If only on ASA - need statin + BP control
NO advantage to PFO closure
Only A/C if concurrent AF
PFO
does not infer inc’d future stroke risk
PFO closure
2nd event after on appropriate medical therapy (ASA/statin)
No flow complication (ie RH enlargement, pulm HTN, AF) - does happen in ASD
AAA rupture risk
Any Sx patient Asx patients: >5.0cm 20% >6.0cm 40% repair if >5.5 or growth >1cm in 1 year Serial imaging 4.0-5.4 q6-12mo
Endoleaks
Type 1: leak from seal at prox or distal end
Type 2: Leak from branch vessel entering grafted area (ie lumbar, mesenteric, testicular) - MC?
Type 3: leak from anastomasis between graft parts
Type 4: Leak through graft material
Aorta replacement
> 5.5 cm or >0.5cm/year growth
If concominent aortic valve surgery replace aorta if >4.5cm
Sx Carotid stenosis
check carotid duplex
need CEA within 2 weeks
Screening Fhx Aortic dissection
screen for BAV with echo Image entire aorta if 1st deg relative died of Ao Diss Marfan's - fibrillin Loey Dietz - TGFB1 Turner's XO Ehrler danolos - COL3A-1 BAV
Intramural hematoma
Crescent shaped eccentric hyperenhancing thickening of aortic wall on non-contrast CT (need non-contrast to dx)
Aneuysm
1.5x normal
CLI
Tyrosine kinase inhibtiors ie nilotinib - cause increased thromobitic events
(oral contraceptives cause VENOUS thormbois not arterial)
PE
if low probability - check D -dimer - 99% NPV ECG - sinus tach, S1, Q3T3 RBBB/iRBBB AF Strain pattern V1-4\ CTA chest V/Q scan Not MRA (low sensitivity)
May Thurger syndrome
iliac vein compression syndrome - young adult
overlying artery compresses iliac vein
missed on LE duplex’
causes leg swelling, varicosities, DVT, stasis ulcers,
FMD
Young woman with HTN and no other features (no buffalo hump, flushing, diarrhea, palpitations, murmurs, pulse delays)
Check renal duplex -> CT/MR if non-dx
Dexasome suppression if buffalo hump
CT/TTE - coarctation
metanephrines - pheo
RAS
inc in Cr with ACE/ARB use atherosclerotic CV dz elsewhere age abdominal bruit recent loss of BP control
RAS
p/w HTN crisis or pulmonary edema
Screening for Aortic aneurysm
marfans
6 mo after dx - yearly if stable
>4.5 - more frequent
replacement at
Aortic aneurysm replacement
> 5.5 in all
>5.0 in marfans (>4.5 if other aortic surgery needed ie AVR)
CLI
need revasc
Cilastozol
contraindicated with HF (use pentoxaphyline)
Takaysu Arteritis
Large vessel arteritis young woman
interarm BP diff
Aorta or primary branches (ie carotid, SC)
Tx: Glucocorticoids before thinking about surgery
Carotid - more mid and distal narrowing (as opposed to proximal in atherosclerosis)
Giant cell arteritis
Large vessel - older patients >50yo
CVA, h/a, ocular sx, inflamm syndrome, jaw claudication, blindness
Tx: high dose steroids
