Vascular Disease Flashcards
Signs / symptoms of chronic limb ischemia
Rest pain Ischemic ulcers Gangrene Elevation pallor Dependent rubor Sx > 2 weeks
Thromboangiitis Obliterans (Buerger’s Disease) features
Age < 40 Smoker M > F Distal and proximal arteries and veins Superficial thrombophlebitis
Treatment for thromboangiitis obliterans
Smoking cessation
Iloprost for pain
ABI calculation
Highest ankle pressure / highest brachial systolic pressure
Normal ABI
1 - 1.4
Abnormal ABI
<0.9
Borderline ABI
0.91 - 0.99
Non-compressible ABI
> 1.4
Exercise ABI for symptomatic patients indicated for
Borderline or normal ABI
Positive exercise ABI
Decrease in ABI by 20%
Decrease in ankle pressure > 30 mm Hg
TASC classification for aorta-iliac and femoral-popliteal PAD A
Short focal stenosis or occlusion
Endovascular
TASC classification for aorta-iliac and femoral-popliteal PAD B treatment
Endovascular repair
TASC classification for aorta-iliac and femoral-popliteal PAD C treatment
Surgery unless high risk
TASC classification for aorta-iliac and femoral-popliteal PAD D
Long stenosis or occlusion
Surgery
Indications for intervention for stable PAD
Lifestyle limiting symptoms +
Inadequate response to exercise and OMT or
favorable risk benefit ratio
Chronic critical limb ischemia treatment
<2 year survival -> balloon
>2 year survival -> bypass
Acute limb ischemia features
Pain Pulselessness Pallor Parasthesias Poikylothermia Paralysis
Acute limb ischemia duration
<2 weeks after symptom onset
Acute limb ischemia causes
Embolism
Thromobis
Dissection
Trauma
Acute limb ischemia stage 1
Viable
+ Doppler
ALI stage 2a
Salvageable
+/- Doppler
+/- Sensory loss
ALI stage 2b
Threatened
No doppler
Paresthesias
Muscle weaknes
ALI stage 3
Non-viable No doppler Profound sensory loss Paralysis -> Amputation
ALI treatment
Endovascular < 2 weeks (Cather lyrics +/- device)
Surgical if > 2 weeks
Lytics contraindicated:
Recent surgery
Intracranial neoplasm / injury
Bleeding risk
Infected graft
Who to screen with US for AAA
Physical exam features of enlarged aorta, atheroembolism, peripheral aneurysm
1st deg FH in men > 60
Men smoking hx 65-75
Symptomatic PAD
Surveillance for AAA with US or CTA < 4 cm
3 years
Surveillance for AAA with US or CTA 4-4.9 cm
12 months
Surveillance for AAA with US or CTA 5-5.4 cm
6 months
Indications for AAA surgery
Diameter > 5.5 cm Expansion > 1 cm in 1yr Symptomatic Rupture / contained rupture Infectious or inflammatory
Endoleak 1 from AAA EVAR
Leak at graft attachment
Need to fix
Endoleak 2 from AAA EVAR
Retrograde flow from collateral arteries
May resolve on follow-up imaging
Endoleak 3 from AAA EVAR
Leak in endograft components
Need to fix
Genetic causes of TAA
Marfan Loeys-Dietz Ehlers-Danlos BAV Familial non-syndromic
Acquired causes of TAA
GCA Takayasu Infectious HTN Toxic Idiopathic
TAA preventive repair cut-off for Turner’s
Aortic index >= 2.5
TAA preventive repair cut-off for Loeys-Dietz
> 4.0 cm
TAA preventive repair cut-off for Marfan’s
> = 5.0
TAA preventive repair cut-off for BAV
> 5.5
High risk features for TAA when considering repair
FH or personal history of dissection
Rapid enlargement
Planned pregnancy
Intramural hematoma
Hematoma in medial layer of aortic wall
May cause dissection
Manage like dissection
Penetrating aortic ulcer
Aortic plaque becomes ulcerated
Usually descending aorta
Management of penetrating aortic ulcer
HTN, anti-platelet, statins
Surveillance imaging
Surgery
Surgical indications for penetrating aortic ulcer
Ascending aorta
Persistent symptoms
True or pseudo-aneurysm formation
Aorta > 5.5 cm
Suspect carotid dissection
CVA preceded by neck pain or Horner’s syndrome
4Ts for HIT assessment
Thrombocytopenia >50% fall, nadir 20-100
Timing 5-10 days or <1 day with prior heparin
New thrombosis, skin necrosis
No other causes
Duration for provoked PE
3 months
Duration for unprovoked PE
Lifelong
Definition of unstable. massive PE
Shock / hypotension with SBP < 90 or >= 40 drop for >= 15 minutes
Treatment for massive PE
Lytics, catheter directed therapy, surgical therapy
Contraindications to thrombolytics
Brain pathology, bleeding risk
Submassive PE definition
RV dysfunction or positive cardiac markers
APLS classification criteria
Clinical event - thrombosis, thrombocytopenia, fetal loss, valve destruction, skin ulceration
Lab testing - anticardiolipin, b2gp1, lupus anticoagulant
Definitive APLS criteria
> = 1 clinical + >=1 lab
Labs must persist at 3 months
Treatment for APLS
Heparin -> warfarin
Lymphedema causes
Congenital
Cancer or related surgery / radiation
Recurrent infection
Lymphedema features
Waxy skin
Non-painful
Non-dependent edema
Treatment for lymphedema
Compression
Manual drainage
Intermittent pneumatic pumping
Indications for tPA for acute ischemic stroke
Within 4.5 hours of symptoms
NIHSS >= 6
Contraindications to tPA for acute ischemic stroke
Intracerebral hemorrhage, recent GIB <3 months stroke, head trauma, brain / spine surgery Brain / spine tumor PLT < 100, INR > 1.7 Anticoagulation Endocarditis Aortic dissection
Window for mechanical thrombectomy for acute ischemic stroke
Early window up to 6 hours
Up to 24 hours with perfusion imaging
Indication for mechanical thrombectomy for acute ischemic stroke
Large occlusion in anterior circulation
Goal BP for tPA
<185 / 110
Therapy for stroke NIHSS <= 3
DAPT within 24 hours for 21 days
US carotid stenosis >= 50%
Peak systolic velocity >= 125
ICA / CCA 2-4
US carotid stenosis >= 70%
Peak vel >= 230
ICA / CCA >= 4
Carotid stenosis symptoms
Within 6 months
Ipsilateral amaurosis fugax
Contralateral motor / sensory symptoms
Aphasia
Carotid stenosis revasc
50-99% if symptoms
Unclear if asymptomatic
Not CTOs
CEA > CAS
Medical therapy for asymptomatic carotid stenosis
ASA
Statin
Anti-HTN
Medical therapy for symptomatic carotid stenosis
ASA or plavix or ASA + dipyridamole
Contraindication to CEA to know
Contralateral laryngeal nerve palsy
Carotid dissection features
- Middle aged, spontaneous or traumatic
- Pain, Horner’s, ischemic symptoms
- No RCTs of intervention but treat medically
- Anticoagulation or anti platelet therapy (non-inferior)
Carotid FMD features
- 2nd most common location
- Association with SCAD
- Pulsatile tinnitus, HA, TIA /s troke
- May cause dissection
- Antiplatelet therapy and BP control, rarely intervene
US for renal artery stenosis
Peak systolic velocity > 300
Diagnosis of renovascular hypertension
- New increase in BP
- Failure medical therapy
- Increased Cr after ACE-I
- Progressive increase in Cr with ischemic neuropathy
- FMD in young woman
- Recurrent flash pulmonary edema / refractory CHF
Treatment of renal artery stenosis
Stenting for postal atheromatous disease if renovascular hypertension
Stage I PAD
Viable
limb not immediately threatened, no sensory loss, no muscle weakness, audible arterial and venous
Stage II PAD
Threatened
mild to moderate sensory or motor loss, inaudible arterial Doppler, audible venous Doppler.
Stage III PAD
non viable
- major tissue loss or permanent nerve damage inevitable, profound sensory loss, anesthetic,
- profound muscle weakness or paralysis (rigor), inaudible arterial and venous Doppler.
May Thurner Syndrome
Iliofemoral DVT due to R common iliac overlying and compressing left common iliac vein against lumbar spine
Preferred anti-platelet for stroke secondary prevention
Plavix
Rapid VKA reversal
4F PCCs
1000u for any bleed
1500u for intracranial bleed
INR 2-4 25 U/kg, 4-6 35 U/kg, >6 50 U/kg
