1. Excertion leg symptoms 2. Age >65yo 3. Age >50yo with h/o tobacco use OR DM 4. Non-healing LE wounds

1. Men >60yo with 1st deg relative with AAA 2. Men >65-75yo who EVER smoked

Vascular Flashcards by Sunil Singh

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

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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

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Screening for PAD

Excertion leg symptoms
Age >65yo
Age >50yo with h/o tobacco use OR DM
Non-healing LE wounds

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Screening for AAA

Men >60yo with 1st deg relative with AAA

2. Men >65-75yo who EVER smoked

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Pulmonary embolism Clinical presentation

Chest pain, dypnea, hypoxia, sinus tach in setting of normal chest xray and clear lungs

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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

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Dx of PAD

If normal resting ABI
then need exercise ABI (treadmill)
TBI if ABI is non-compressible (ie >1.3)

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Sx PAD therapy

Supervised excercise - improved 6MWT
Cilostozol CONTAINDIC with HF
PENTOXYphline ok but not great

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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

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RAS pathophys

kidney 1 RAS->kidney sense lower vol, kidney 2 secretes renin (angiotensin->aldosterone) - sodium retention->inc’d BP

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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

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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

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Takayasu arterities

Young adult with subacute inflamm illness and h/a and interarm BP diff

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Massive PE

Hypotension
Saddle PE
RV failure -> lytics - if contraindication then catheter directed thrombolysis

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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)

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Symptomatic Carotid stenosis

benefit of carotid endarectomy best within 2 weeks of symptomatic carotid stenosis episode (ie TIA/CVA) >70% STENOSIS

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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

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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)

``` 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