Vascular Flashcards
Primary Raynaud phenomenon causes
autoimmune such as systemic sclerosis, lupus, mixed connective tissue disease, Sjögren and dermatomyositis/polymyositis. Hematologic disease, drugs like meth
Headaches+ jaw fatigability+ shoulder stiffness+ B symptoms+ vision
Mild fevers+ arm fatigue when brushing hair in Asian
Smoking+ ulcers (digit ischemia, raynaud’s, abnormal Allen test)
Giant cell arteritis- temporal artery biopsy-
Subclavian artery stenosis, takayatsu arteritis
Buerger’s disease (thromboangitis obliterans)-> stop smoking
elevation pallor and dependent rubor
draining ulcer over the medial malleolus
toe-brachial index indicated in
PAD
venous insufficiency (arterial ulcers are dry and lateral/distal)
supranormal ABI measurements (>1.4)
urgent repair in type B aortic dissection
renal failure, visceral ischemia, or contained rupture
neck pain or horner’s syndrome before CVA
carotid artery dissection
Acute limb ischemia
viable
threatened
irreversible
<2 weeks of symptoms
senses and strength intact, audible doppler-> angiography, urgent revasc (6-24 hrs)
mild-moderate loss of senses/strength, inaudible arterial doppler, audible venous doppler -> angiography, emergent revasc (w/in 6 hours, do not image first)
profound loss, inaudible arterial+ venous -> amputation
highest mortality in aortic dissection
higher mortality in type B dissection
involving the aortic root
Partial thrombosis of the false lumen
Cryptogenic stroke
Causes of stroke: afib, carotid artery disease, PFO
Stroke of undetermined origin (not afib/ carotid artery)
<= 60 yo= PFO closure + antiplatelet
If none of the three present, 30 day monitor to look for afib
CEA indicated in
significant symptomatic carotid stenosis, defined as stenosis >70%
Prasugrel CI in
history of TIA or stroke
Acute infarct on CT
blurring of the gray–white matter interface
Cholesterol emboli syndrome diagnosis
Treatment
Clinical
Supportive, statin therapy, no AC indicated
Mesenteric ischemia diagnosis
Revasc if
CTA of abdomen
symptomatic
patients with PAD 5 year prognosis
More heart specific (MI/stroke) events than limb specific events
PAD will most likely be stable
Critical limb ischemia
Treatment
rest pain, nonhealing ulcer, dry gangrene
ABI-> Invasive Imaging and revasc (do not get noninvasive angiogram)
Dabigatran and edoxaban
Need to be preceded by 5-10 days of lovenox
HTN in acute ischemic stroke
If no thrombolysis, only treat if >220/120
If thrombolysis, lower below 180/110 before, keep below 180/105 for 24 hrs
If acute aortic dissection, pre-eclampsia, eclampsia, unstable coronary syndrome, or acute heart failure-> lower BP goal
Hypertensive encephalopathy imaging
Cerebral edema may be seen on T2 weighted images on MRI
Ischemic cerebral injury causes
Best imaged on
Cerebral edema
MRI
Takayasu arteritis imaging
Diagnosis
Thickening of aortic wall
3 of:
1) age of onset <40 years; 2) intermittent claudication; 3) diminished brachial artery pulse; 4) subclavian artery or aortic bruit; 5) systolic blood pressure variation of >10 mm Hg between arms; and 6) angiographic (computed tomography, magnetic resonance) evidence of aorta or aortic branch vessel stenosis (Figure 1)
Takayasu treatment
Steroids
Behcet’s imaging
Diagnosis
Small aneurysms at multiple sites and affecting both arteries and veins
oral ulceration and two of these three lesions: recurrent genital ulceration, uveitis or retinal vasculitis, or skin lesions, such as erythema nodosum, pseudofolliculitis, or pathergy.
GDMT for PAD
Ticagrelor+ aspirin for
high-intensity statin therapy regardless of LDL level to achieve a 50% LDL reduction.
Symptomatic PAD and prior MI (regardless of stents)
Aspirin or plavix for everyone. Also consider low dose rivaroxaban+ aspirin if low bleeding risk
May-Thurner syndrome
Diagnosis
right common iliac artery overlies and compresses the left common iliac vein against the lumbar spine= DVT
LLE swelling when there’s no DVT
MRI of the pelvis
Crescentic, high attenuation area in aorta that does not enhance with contrast
Intramural hematoma -> emergent surgical repair
Same with penetrating aortic ulcer
Major bleed on anticoagulation
Reverse
Warfarin- use prothrombin concentrate complex (kcentra), 1000 units for any bleed and 1500 units for intracranial bleed
Dabigatran- idarucizumab
Rivaroxaban and apixaban- andexanet alfa
Claudication + normal ABI
Diagnosis
Get exercise ABI
A decrement of >20% in ABI values with exercise is diagnostic of arterial obstruction.
Elective repair of Asymptomatic AAA
2.5 cm but ≤5.5 cm;
rapid expansion;
AAA associated with peripheral arterial aneurysms or peripheral artery disease.
AAA screening intervals
- 5 cm but <3.0 cm, 10 years
- 0-3.9, repeat imaging every 3 years
- 0-4.9, repeat imaging in 12 months
- 0-5.4, repeat imaging in 6 months
Carotid artery stenosis <70%
Medical management with annual screening
Carotid artery stenosis may be overestimated in
If Contralateral artery is occluded
Secondary stroke prevention
Plavix better (safer) than aspirin
5 Ps of limb ischemia
pain, pallor, paralysis, pulse deficit, paresthesia, and poikilothermia
First degree relatives of patients with bicuspid aortic valves
Aortic imaging with computed tomographic (CT) angiography or magnetic resonance (MR) imaging/MR angiography
ABI calculation
Only systolic numbers
Pre CABG testing
Carotid duplex if
ABI if
65 yo/ left main coronary artery stenosis/ PAD/ history of smoking, history of stroke/transient ischemic attack, or carotid bruit.
Symptomatic
