Vascular Disease Flashcards
Atherosclerotic Peripheral Vascular Disease: aorta and iliac
-Systemic atherosclerotic process
-Present in 30% of 70 yo patients without risk factors, 30% of 50 yo with risk factors.
-Increased risk in diabetics, tobacco use, >70 yo
-Lesions in the distal aorta and proximal common iliacs classically occur in white male smokers age 50-60 yo
-Progression may lead to complete occlusion of one of both iliac arteries
-Mortality from the cardiac disease is 25-40% at 5 years
Atherosclerotic Peripheral Vascular Disease: aorta and iliac S&S
-2/3 asymptomatic or not classic
-Intermittent claudication
-Aortoiliac cramping can be in thigh and buttocks -> Erectile dysfunction -> Eventual rest pain
-Symptoms are relieved with rest and reproducible with the same exertion!
-pts may dangle foot off bed so gravity helps
-Femoral and distal pulses are absent or weak -> Bruit may be heard over the aorta, iliac or femoral
-Leriche’s syndrome! (Triad of impotence, claudication and decreased femoral pulse)
DX
-Ankle Brachial Index:
-Calculate ABI by dividing the blood pressure in an artery of the ankle by the blood pressure in an artery of the arm
-<0.9 PAD, <0.4 critical limb ischemia
-ABI measured using the dorsalis pedis and posterior tibial arteries
-CT angiography and MRI can identify anatomic location of the lesion
TX
A
-Risk factor reduction… stop smoking! (more so with this disease)
-walking is the best*
-High dose statin for plaque stabilization
-Phosphodiesterase inhibitors (Pletal/cilostazol)
-Aspirin to reduce cardiovascular morbidity (mortality 25-40% at 5 years)
-Angioplasty and stenting -> closure 30-50%!
-Bypass surgery (Axillo-femoral, fem-fem bypass) patency 90% at 5 years
atherosclerotic peripheral vascular disease: femoral and popliteal
-Usually occurs 10yrs after aortioiliac disease.
-usually at abductor magnus tendon in the distal thigh (ductus hiatus)
-Less common in common femoral and popliteal but these lesions are debilitating
-Calf cramping
-Rubor (red) of the foot with blanching on elevation
-Atrophic changes in the lower leg and foot
-Loss of hair, thinning of skin & tissue, atrophy of muscle.
-Severe can have gangrene or ulcers
-Reduced popliteal and pedal pulses (not femoral -> distal)
-should only have toe nails cut by podiatrist
-work up:
-Reduced ABI <0.9
-Duplex Doppler- see reduction in pulse
-CTA
-MRI
-tx:
-Risk factor reduction
-Medical therapy same as Aortioiliac
-Exercise Program
-Femoral- Popliteal Bypass
-Angioplasty and stenting (< 10 cm):
-1 yr patency 50% angioplasty, 80% stenting
-3 yr restenosis common -> <50% patent
-Thromboendartectomy
-Common femoral & profunda femoris -> Where bypass and stenting less successful
atherosclerotic peripheral vascular disease: tibial and pedal
-Severe pain in the foot that is relieved by dependency.
-Pain or numbness in the foot with walking (no blood supply)
-Primarily in diabetics
-S&S:
-May not have claudication symptoms -> can be distal to calf (just foot)
-Rest pain & Ulcerations: Critical limb ischemia! High rate of amputation.
-Typically awakened with dorsal foot pain -> Pain relieved with dangling foot in dependent position off bed.
-Pedal pulses absent.
-Pallor on elevation
-Skin cool, atrophic and hairless
-work up:
-ABI low. (<0.4 critical limb ischemia)
-Digital subtraction angiography *
-MRI and CT not as useful with small vessels
-tx:
-Good foot care
-If non-healing ulceration after 2-3 weeks needs revascularization to avoid amputation.
-Bypass to distal tibial- 70% patent at 3 years.
-Amputation
acute aterial occlusion of limb
-Sudden pain in an extremity with an absent extremity pulse!
-Cardiac emboli (think AF), thrombosis, hypercoagulable (hormone therapy, cancer, obese, sedentary)
-Signs and Symptoms
-pain, pallor, pulselessness, and poikilothermia (cold)*
-Pain is localized and less severe when limb is dependant
-eventually -> paresthesia and paralysis*
-6 Ps
-Livedo reticularis: lacy pattern on the skin -> Mottled vascular pattern
-Work Up:
-Little to no flow on Doppler.
-In the procedure angiography
-Don’t delay with an MRI or CT, only with low suspicion.
-Treatment:
-IMMEDIATE REVASCULARIZATION! Should be within 3 hrs, by 6 hrs irreversible!
-IV heparin
-Tissue plasminogen activator, TPA
-Thromboembolectomy
-10-25% risk of amputation, 25% hospital mortality rate
occlusive cerebrovascular disease
-Sudden onset of weakness and numbness of extremity or the face, aphasia, dysarthria or unilateral blindness (amaurosis fugax)
-Emboli.
-Transient ischemic attach, TIA. Reversible when collateral flow reestablishes profusion but has future risk for stroke!
-¼ of ischemic strokes from arterial source. 90% of these from proximal internal carotid artery
-S&S:
-TIA last seconds to minutes
-Stroke >24 hrs
-Emboli to retinal artery causes amaurosis fugax
-Carotid artery bruit, loudest mid neck
occlusive cerebrovascular disease: workup and tx
-workup:
-Duplex Ultrasound for carotid stenosis
-MRA
-CTA
-afib
-Treatment
-CVA management
-If >60% carotid stenosis then intervention:
-Carotid Endartectomy
-Angioplasty and stenting*
-25% will have recurrent CVA if no intervention
-If 30-50% stenosis monitor and risk factor modification
-F/u with US monitoring
visceral artery insufficiency
-Acute is emboli or thrombus to major mesenteric vessel. Often pain out of proportion to initial clinical findings.
-Low flow state from CHF or hypotension
-Chronic from adequate at rest but ischemic when flow demands increase after eating.
-Usually two of three vessels have occlusive disease if symptoms being there is collateral circulation (celiac, SMA, IMA, marginal)
-Severe post prandial abdominal pain
-Weight loss with fear of eating
-Ischemic colitis -> IMA intestinal mucosa will slough -> Consider in post operative aortic patient!
-if pt has large bowel movement post op -> consider that you blocked the bowel blood supply
visceral artery insufficiency: S&S (labs too)
-Acute: severe, steady epigastric and periumbilical pain
-No findings on physical exam (visceral not parietal peritoneum)
-High WBC, lactic acidosis, hypotensive, abdominal distention
-Chronic: evidence of other atherosclerosis -> Epigastric or periumbilical pain lasting 1-3 hrs after eating -> Patient starts to limit eating
-Ischemic colitis: left lower quadrant pain and tenderness, abdominal cramping and mild diarrhea often bloody
visceral artery insufficiency: workup and tx
-Work Up:
-CT with contrast
-US may show proximal lesion.
-Colonoscopy may show ischemic changes in colitis.
-Treatment:
-Acute: Surgical exploration
-Chronic: angioplasty and stenting
-Ischemic Colitis: support until collateral circulation can be established -> Surgical resection for perforation
-10-15% mortality with intervention
-Usually fatal if no intervention
thromboangitis obliterans/buerger disease
-Inflammatory and thrombotic process of the distal most arteries and occasionally the veins.
-vasculitis due to smoking!
-Typically male.
-Severe ischemia of the feet, fingers and hands.
-Patient usually younger than 40 yo.
-Pain in distal extremity, tissue loss and amputation unless they stop smoking
-Work up:
-MRA or invasive angiography
-Treatment:
-Stop smoking!
-If does not stop smoking prognosis is poor with extremity amputations
giant cell arteritis
-Systemic inflammatory condition of the medium and large vessels.
-Primarily older than 50 yo and coexists with polymyalgia reheumatica
-Frequently involves the temporal artery “temporal arteritis” and other branches of carotid artery.
-If not treated can cause blindness.
-Large vessel problems occur in 15% of patients within 7 years.
-May have varicella / zoster relationship
-Complain of unilateral temporal headache, Scalp tenderness, jaw claudication, throat pain, diplopia and elevated inflammatory markers.
-Work Up
-Erythrocyte sedimentation rate and C-reactive protein elevated.
-Temporal artery biopsy.
-Temporal ultrasound may show thickening
-Treatment
-High dose prednisone and low dose Aspirin
aortic aneurysm
-Weakness and subsequent dilation of the vessel wall, genetic defect, syphilis, giant cell arteritis, vasculitis, trauma, Marfan syndrome, Ehlers- Danlos syndrome or atherosclerotic damage (MC) to the intima.
-MC in men 4:1, smokers.
-Asymptomatic until rupture
->3 cm diameter of abdominal aorta. AAA
-Risk of rupture >5 cm. 80% are palpable on exam.
-90% of AAA are below the renal arteries.
-Usually involve the aortic bifurcation and often common iliac arteries
aortic aneurysm S&S
-Most found as an incidental finding on US or CT
-Pain
-During rupture: severe pain, palpable abdominal mass and hypotension
-Lethal.
aortic aneurysm: workup
-Screen men 65-75 yo smokers
-1st degree relative screen women.
-Abdominal Ultrasound
-CT scan for diameter and anatomical location
-Surveillance :
-Annual ultrasound
-Every 6 months US approaching 5 cm
-CTA with contrast to define anatomy for repair once reaches 5cm
AAA tx
->5.5 cm or rapid expansion intervention (0.5cm in 6 months)
-Unless life expectancy <2 years due to other comorbidities.
-Open surgical repair a graft is sutured to the nondilated vessel above and below.
-Endovascular repair a stent graft is used to line the aorta and exclude the AAA.
-MI complication 10% with surgical repair
thoracic aortic aneurysm
-Most asymptomatic
-Risk Factors: HTN, 50-60 yo, collagen disorder, vasculitis, family history.
-Back and neck pain, dyspnea, stridor, cough, dysphagia, hoarseness (recurrent laryngeal), distended neck veins.
-May have aortic valve involvement in ascending aneurysm.
-Rupture almost always fatal.
-CXR may show widened mediastinum
-CT scan
->6 cm for repair
-Surgical or endovascular
-Surgical risk of paraplegia -> risk of vertebral artery loss (supply to spinal cord)
peripheral artery aneurysms
-Usually silent until critically symptomatic.
-Present as embolization or thrombosis.
-70% popliteal. 60% of the time they are bilateral! 50% of these patients also have a AAA!
-Pulsatile mass
-Investigate with ultrasound. MRA or CTA to define. Screen for AAA.
-Surgical repair with bypass
aortic dissection
-Spontaneous intimal tear and blood dissects into the media of the aorta
-false lumen
-Sudden searing chest pain with radiation to the back, abdomen or neck
-Hypertensive
-Syncope, hemiplegia, paralysis of lower extremities.
-Intestinal ischemia and renal insufficiency may develop
-Pulses may be diminished or unequal.
-MRA Gold Standard 100% S&S
-CXR shows widened mediastinum
-CT Chest and Abdomen for diagnosis.
-Surgical intervention required!
varicose veins
-Superficial veins distended due to progressive venous reflux.
-20% of adults, women who have been pregnant, obesity, family history, prolonged sitting or standing.
-Distribution of great saphenous vein.
-Can be asymptomatic or ache.
-Elastic stockings, leg elevation and exercise for relief.
-Surgical stripping, thermal ablation, sclerotherapy
superficial venous thrombophlebitis
-Partial or complete occlusion of a vein and inflammatory changes.
-Induration, redness and tenderness along a superficial vein
-Usually at the site of a recent intravenous line ->
-Usually Staphylococcus aureus.
-Spontaneous or site of varicose veins
-Can be caused by systemic hypercoagulopathy in abdominal cancer!!*
-Spontaneous treat with heat and NSAIDs
-Antibiotics for infectious
chronic venous insufficiency
-Loss of wall tension in veins, which results in stasis of venous blood and often is associated with DVT, leg injury, or varicose veins.
-Hemosiderian deposits cause dark pigmentation -> Breakdown of leaked hemoglobin into the interstitial space.
-Prevention is key!
chronic venous insufficiency
-Progressive pitting edema starting at the ankle followed by skin and subcutaneous changes
-Itching, dull pain with standing
-Ulcerations just above the ankle
-Skin is shiny, thin and atrophic with dark pigment changes
-medial malleolous- more likely to have weeping lesions
-swelling
chronic venous insufficiency: tx
-Elevation of legs
-Avoid extended sitting or standing
-Compression stockings (NOT arterial -> you would compress arteries
-Surgical treatment: Ligation or stripping
superior venal caval obstruction
-Swelling of the neck, face and upper extremities. Dilated veins over the upper chest and neck.
-Partial or complete obstruction of the SVC usually secondary to neoplastic or inflammatory process in the superior mediastinum
-usually lung cancer obstruction
-Bending over or lying down accentuates the symptoms.
-CT for diagnosis.
-Treat underlying cause and possible stenting.
deep venous thrombosis (DVT)
-Lower extremities and pelvis
-Virchow’s triad
-Statis
-Vascular injury
-Hypercoagulability
-Increased with major surgical procedures, bed rest, lower extremity trauma, use of oral contraceptives, hormone therapy, cancer and and inherited coagulopathy.
-Risk factors: age, obesity, long distance air travel, multiparity, inflammatory bowel disease and lupus erythematosus
acute mesenteric vein occlusion
-Post prandial pain and evidence of a hypercoagulable state
-Presents similar to arterial occlusive syndromes however is less common
-clotted off part of portal circulation
-Risk Factors:
-Paroxsymal nocturnal hemoglobinuria, Protein C, Protein S, Antithrombin deficiencies or JAK2 mutation
-Thrombolysis is mainstay therapy
-Aggressive long-term anticoagulation
DVT: dx and tx
-Half of patients have no symptoms or signs.
-Can have swelling of the involved area with erythema and warmth.
-Duplex US
-D-Dimer is elevated in presence of DVT but is not diagnosis!
-If PE suspected, CTA and VQ scan
-Prevent with compression devices on bedridden patients
-Heparin
-Novel anticoagulants
questions in the PP
