VASCULAR DISEASE Flashcards
arterial vasc ds- atherosclerotic peripheral vascular ds
can affect what arteries?
aorta and iliac
femoral and popliteal
tibial and pedal
atherosclerotic PVD
- aorta and iliac
- present in what kind of pts
- inc risk in?
- distal lesions in what pts?
- 30% of 70 yo w out RF, 3-% of 50 yo WITH RF
inc risk- DM, tobacco use, >70 yo
distal aorta/proximal common iliac lesions- white male smoker 50-60 yo
atherosclerotic PVD
aorta and iliac- SS
2/3 ASYMP (not classic)
MC- intermittent claudication (pain from insuff BF when there is inc demand from exercise), inc cramp in calf
- butt/thigh cramp
- erectile dysnfunc
atherosclerotic PVD
aorta and iliac- how are symp relieved
relieved with rest, reproducible w same exertion
atherosclerotic PVD
aorta and iliac- signs
- absent or weak femoral and distale pulses
- bruit over aorta, iliac, or femoral
- leriches syndrome (triad of impotence, claudication, and dec femoral pulse)
atherosclerotic PVD
aorta and iliac- work up
ABI reduced <0.9 is PAD
ABI <0.4 is critical limb ischemia
ABI measured using dorsalis pedis and posterior tibial aa.
CT angio and MRI to identify lesion
atherosclerotic PVD
aortia and iliac- tx
conservative, meds, and surgical options
conservative- control RFs (smoking)
meds-
- control HLD, HTN
- high dose statins DAILY, plavix DAILY
- control pain- pletal
- dec morbidity- ASA
surgical
- angio or stenting at 30-50% closure
- bypass at 90% closure
atherosclerotic PVD
femoral and popliteal
- when does it occur and where
occurs decade after aortoiliac
- at site of adductor hiatus
atherosclerotic PVD
femoral and popliteal- signs and symptoms
symptoms
- calf cramp
- red foot, blanching w elevation
- hairless, shiny, atrophy muscle
- some gangrene or ulcer
signs
- dec pedal and popliteal pulses
atherosclerotic PVD
femoral and popliteal- work up
reduced ABI <0.9
duplex doppler
CTA
MRI
atherosclerotic PVD
femoral and popliteal- tx
conservative, meds, and surgical
conservative- reduce RFs, exercise
meds-
- high dose statins and plavix DAILY, ASA, pletal
surgical-
- fem-popliteal bypass
- angioplasty or stent
- thromboendarectomy if angio or stent fails
atherosclerotic PVD
tibial and pedal- clin features
severe pain in foot, relieved by dependency (hang foot off bed/remove gravity)
- pain or numbness in foot w walking
- primarily diabetics
atherosclerotic PVD
tibial and pedal- symptoms and signs
may NOT have SS of claudication
- pain and ulcerations
- dependency, dangle foot off bed for relief
- dorsal foot pain wakes pt up
- critical limb ischemia common
signs
- absent pedal pulses
- pallor on elevation
- cool, hairless, atrophied skin
atherosclerotic PVD
tibial and pedal- work up
- ABI low (critical lim <0.4)
- DSA (digital subtraction angio)
atherosclerotic PVD
tibial and pedal- tx
- good foot care
- non healing ulcerations after 2-3 weeks need revasc to avoid amputation
- bypass to distal tibial
- amputation
acute arterial occlusion of a limb
- initial sign
SUDDEN pain in extremity with absent extremity pulse
- cardiac emboli (afib), thrombosis, hypercoaguable
acute arterial occlusion of a limb
- signs and symptoms
6 Ps- pain (localized), pallor, pokilothermia, pulselessness, paresthesia, paralysis
livedo reticularis- lacy pattern on skin/mottled vascular pattern
initial- pain, pallor pokilo, pulseless
later/final- paresthesia, and then paralysis
acute arterial occlusion of a limb
- work up
- doppler (little to no flow)
- angiograph
- dont delay w MRI or CT
acute arterial occlusion of a limb
-tx
IMMEDIATE REVASC
- within 3 hrs, by 6hrs its irreversible
- IV heparin
- TPA (tissue plasminogen activator)- clot buster
- thromboembolectomy
- risks of amputation
occlusive cerebrovascular ds
clin features
definition- blocked or narrowed vessels to brain
SUDDEN onset weakness and numbness of extremity
or
face aphasia, dysarthria, or unilateral blindness (amaurosis fugax)
- can manifest as emboli, TIA (reversible if collateral flow establishes), can turn into stroke
aphasia and dysarthria- both cause trouble speaking
occlusive cerebrovascular ds- risk of turning into stroke from what artery?
1/4 ischemic strokes from arterial source, 90% from proximal internal carotid artery
occlusive cerebrovascular ds
- signs and symptoms
- TIA last seconds to minutes
- stroke >24 hrs
- emboli to retinal artery (amaurosis fugax)
- carotid artery bruit, loudest mid neck (hold breath)
occlusive cerebrovascular ds
- work up
- duplex US for carotid stenosis
- mra
- cta
occlusive cerebrovascular ds- tx
- CVA management
- > 60% carotid stenosis, intervene (carotid endarectomy, angioplasty/stenting)
- 25% recurrent CVA if no intervention
- 30-50% stenosis, monitor and RF mods
visceral artery insufficiency
- what happens
- causes
acute emboli or thrombus to major mesenteric vessel
- low flow state from CHF or hypotension
- 2 out of 3 (SMA, IMA, celiac) blocked to show symptoms (collateral circ usually will take over with 1 blockage)
visceral artery insufficiency
- clinical features
- chronic–>Gi is at rest, adequate blood flow
- ischemic—> after eating, GI demands blood flow and blockage causes ischemia (not adequate)
- severe POST PRANDIAL abd pain
- wt loss w fear of eating
- ischemic colitis
- IMA intestinal mucosa slough off
visceral artery insufficiency- signs and symptoms
acute, chronic, IC
acute- severe, steady epigastric/periumbilical pain
- high WBC, lactic acidosis, hypoten, abd distenstion
chronic- other atherosclerosis, epi/peri pain lasrt 1-3 hrs after eating, pt limits eating
ischemic colitis- LLQ pain tender, abd cramp, mild bloody diarrhea
visceral artery insufficiency
- work up
- CT w contrast
- US (proximal lesion)
- colonoscopy (for IC)
visceral artery insufficiency- tx
acute- surgical exploration
chronic- angio and stenting
IC- support until collateral circ established
- surgical resection for perforation
thromboangitis obliterans/buerger ds
what is it
clin features
inflamm and thrombotic proess of DISTAL most arteries and sometimes veins
- SMOKERS.
- male
- SEVERE ischemia feet, fingers, hands
- pt usually <40 yo
- pain in distal ext, tissue loss, amputation unless STOP SMOKING
thromboangitis obliterans/buerger ds
important sign
gangrene on finger tips !!!!!!!!!!
pain in distal ext, tissue loss, amputation unless smoking cessation
thromboangitis obliterans/buerger ds
- work up
- tx
MRA or invasive angiography
STOP SMOKING
if not working, poor prognosis (amputation)
giant cell arteritis
sys inflamm of medium/large vessels
- temporal artery
- >50 yo
- polymyalgia rheumatica assoc
giant cell arteritis
- not tx what happens
- associated with?
- signs and symptoms
can cause blindness if not tx
can be assoc w varicella/zoster
ss:
unilat temporal headache, jaw claudication, diplopia, elevated ESR/CRP
giant cell arteritis- work up and tx
ESR, CRP elevated
temp artery bx
temp US (thickening)
tx- high dose prednisone, low dose aspirin
aortic aneurysm
- what is it
- mc in
- symp?
weakness and dilation of vessels wall, genetic defect, syph, GCA, trauma, marfans, ehlers danlos, or atheroscle damage to intima
MEN, SMOKERS
- asymp till rupture
- if abd aorta is >3 cm—> AAA.
- risk of rupture >5 cm
common site of AAA?
what arteries do they usually include?
90% are below the renal arteries
usually involve aortic bifurcation and common iliac arteries
AAA- SS
incidental finding US or CT
- rupture–> severe pain, palpable abdominal mass, hypotension, LETHAL
AAA- work up
screening, reg work up, suveillance
work up
- screen men 65-75 smokers, 1st degree relative screen women
- abd US, CT scan for diameter and location
- surveillance: annual US, 6 month US approaching 5cm, CTA w contrast for repair once reaches 5 cm
AAA- tx
> 5.5 cm or rapid expansion (0.5 cm in 6 month)—> INTERVENE
- open surgical repair, graft sutured to nondilated graft above and below vessel
- endovasc repair, stent graft lines aorta to exclude AAA
- mi complication
thoracic aortic aneurysm
- rf, SS, testing, DX, criteria for tx
ASYMP
- RF: HTN, 50-60 yo, collagen d/o
- SS: back/neck pain, STABBING, dysphagia/hoarseness, JVD
- rupture is fatal
- CXR–wide mediastinum
-Dx–CT
- >6 cm for REPAIR (surgical or endovasc)
peripheral artery aneurysms
- ss, clin feature, defining feature, dx, tx
- asymp till critically symp
- emboli or thrombosis
- popliteal, usually BIL, most have AAA too
PULSATILE MASS
dx- US, MRA, CTA, screen for AAA
tx- surgical repair w bypass
aortic dissection
- SS, complications, gold standard, dx, tx
intimal tear, blood goes into media of vessel
SS- searing CP back, abd, or neck, HTN
complications- syncope, hemiplegia, or renal insuff may develop
MRA is GOLD STANDRARD
dx w/ CT abd and chest
CXR shows widened mediastinum
varicose veins
superficial veins distended due to venous reflux
- prolonged sit/stand, pregnant, obese
- GREAT SAPHENOUS VEIN
- use compression stocking, leg elevation, exercise for relief
- tx- surgical stripping, thermal ablation, sclerotherapy
superficial venous thrombophlebitis
partial or comp occlusion of a vein AND inflamm changes
- induration, red, tender alone superifial vein (or site of recent IV line)
- S.AUREUS
- can be caused by hypercopagulopathy in ABD CANCER
tx- Heat and NSAIDS, abx for infx
chronic venous insuffciency- clin features
loss of wall tension in veins—venous statis—assoc w DVT/leg injury/or varicose veins
hemosiderian deposits–DARK pigment (breakdown fo HgB into intestitial space)
PREVENTION IS KEY
chronic venous insuff- SS and TX
SS- pitting edema at ANKLE, itching/dullpain with standing, ulcerations above ankle, shiny/thin/atrophied dark pigment skin
tx- elevate legs, avoid sit/stand, compression stockings, surgical ligation or stripping
superior venal caval obstruction
- ss, dx, tx
sweling neck, face, upper ext
dilated veins upper chest and neck
- PARTIAL or COMP obstruction of SVC (secondary to neoplastidc or inflamm process in mediastinum)
BEND over or LAY DOWN—exaggerates symptoms
dx- CT
tx underlying cause, stenting
DVT
- clin features, ss, rf, dx, prevention, tx
- if PE suspected what tests
lower ext and pelvis
- virchows triad
- inc w major surgeries, bed rest, trauma, cancer
rf- age, obesity, air travel, IBD, lupus
no SS or swelling/warmth
dx- duplex US, D dimer elevated (not dx)
prevention- compression devices on bedridden pt, heparin, anticoag
if PE suspected— CTA and VQ
acute mesenteric vein occlusion
post prandial pain AND evidence of hypercoaguable state
- thrombolysis tx
- aggressive long term anticoag
ex) GI cancer pt most likely to develop
