vascular disease Flashcards
arterial occlusion
can occur centrally (Aortoilliac)
but generally start peripherally (Femoral, Popliteal, Infrapopliteal)
Typical Etiology:
Atherosclerosis
Often the first sign of disease elsewhere (CAD)
Other Etiologies:
Diabetes: Distal lower extremities, esp. feet, diabetic foot wounds
Thromboembolic: Limbs
typical arterial occlusion at
White, Male, Age 50-60, Smokers
The 5 “P”s of Arterial Occlusion
Pain Pallor Pulselessness (weak/absent distal to the occlusion) Paresthesias Paralysis (need to intervene!)
Pain
Claudication: Severe Cramping associated with exertion
Can be variable, “intermittent”
Inability of blood flow to tissue demands
other manifestations of arterial occlusion
Muscle atrophy
Erectile Dysfunction
Loss of hair of distal extremities
Skin Changes:
Hyperemia, Cyanotic, Dusky Appearing, Cool to Touch
arterial occlusion dx:
Ankle-Brachial Index (ABI)
The ratio of systolic blood pressure detected by doppler examination at the ankle compared to the brachial artery
Normal: ABI 1.0-1.2
Reduced Blood Flow: ABI less than 0.9
art occ dx: critical limb ischemia
Elevated Myglobin (renal failure with rhabdomyalysis)
Metabolic Acidosis
-will be in pain at this point
art occ imaging
Angiography with CT or MR
Mainly for Intervention to Identify affected vessels
-look for runoff:
right pic: left leg lacks runoff
art occ conservative tx
Exercise, weight loss, smoking cessation
Cilostazol (PDE-inhibitors (maintain patency, inc. blood flood)
Antiplatelet agents (ASA, Clopidogrel)
*prevent extension of clot
art occ tx: Endovascular Techniques
Angioplasty and Stenting
art occ tx: sx techniques
Endarterctomy
Bypass Grafting
Critical Limb Ischemia tx
Heparin
Catheter Directed tPA
Thrombectomy
Complications:
Compartment syndrome
Fasciotomy
aneurysm
types??
Pathologic dilation of a BV
saccular (bulge)
fusiform (long and slender)
giant
dissection: high pressure blood flow opens false lumen in intima–>clot, hematoma formation
Diseases Associated with Aneurysms
*Aortic Aneurysms
Berry Aneurysms
Peripheral Aneurysms
congenital etiologies of aneurysms
Marfans Syndrome: defective elastin gene
Ehler-Danlos Syndrome: defective collagen gene
acquired etiologies of aneurysms
Age HTN Smoking, pollution? Inflammation Atherosclerosis Syphilis (mycotic aneurysm) Trauma sx procedures i.e. bypass grafts
Abdominal Aortic Aneurysm (AAA)
Present when Aorta diameter >3cm
Increase risk of rupture >5cm
Found in 2% of men over age 55
90% originate below renal arteries (but before bifurcation)
4:1 Male predominance
AAA s/s
80% of 5cm infrarenal AAA are palpable
Usually found incidentally on CT or U/S
Pain
Rupture
AAA pain
Mild-severe abdominal discomfort
Often radiate to the lower back
Intermittent or constant
Exacerbated with abdominal pressure
AAA rupture
Sudden onset severe pain w/ blood in the retroperitoneum
Palpable mass can be present
Hypotension
medical emergency!
AAA imaging: 1st choice
Abdominal ultrasound is test of choice:
Screening test
USPTF: recommended in Men 65-74yrs with smoking history (not Women)
AAA imaging 2nd choice
CT abdomen:
Useful to assess for size and location
Planning for intervention
Monitor Progression
conservative AAA tx
Smoking Cessation Manage HTN Serial Imaging every 2 yrs if less than 4cm every 6 mos around 5cm
elective sx repair for AAA when ??
> 5.5cm diameter OR
>0.5cm increase in diameter in 6 months
AAA: Absolute Indication for Surgery Consult when ??
Signs suggestive of Rupture or impending rupture:
Acute onset severe abdominal pain with radiation to the back
Hypotension
Cullen Sign: periumbilical ecchymosis
Grey Turner’s Sign: flank ecchymosis
(both signs imply retroperitoneal hemorrhage)
Thoracic Aortic Aneurysm
s/s
less than 10% of all aortic aneurysms
Signs and Symptoms Severe persistent substernal chest pain Radiation to the back/neck Usually Hypertensive Dyspnea, stridor, dysphagia, hoarseness UE Edema
Thoracic Aortic Aneurysm imaging
Chest Xray: Widened mediastinum *CT Chest*: Modality of Choice Echocardiography: may see dilated aortic root, bicuspic aortic valve
Thoracic Aortic Aneurysm tx: only monitoring when ??
Stable Descending Aortic Aneurysm
TAA tx: endovascular repair for ??
Descending Aortic Aneurysm
surgical intervention for TAA
Any Ascending Aortic Aneurysm
-Especially when carotid and left subclavian arteries involved
Descending Aortic Aneurysm >6cm in diameter
Conditions associated with increased risk of aortic dissection:
Pregnancy
Bicuspid aortic valve
Coarctation of the Aorta
aortic dissection s/s
Severe persistent substernal chest pain Radiation to the back/neck Usually Hypertensive Dyspnea, stridor, dysphagia, hoarseness UE Edema Diastolic Murmur Intestinal ischemia Diminished /unequal peripheral pulses Acute Heart Failure Pericardial Tamponade
aortic dissection imaging
CT Chest and abdomen: modality of choice
see false lumen
aortic dissection med tx
Aggressive HTN management
Beta blockers, Nitroprusside
Morphine for pain
aortic dissection sx
Urgent
all Type A
Type B affecting left subclavian artery
Venous Insufficiency May be associated with ??
Obesity Previous leg trauma Previous DVT Varicose veins Neoplastic obstruction AV fistula (congenital or acquired)
Venous Insufficiency basic pathology
Valve leaflets do not close
Increased Hydrostatic Pressure
Causes characteristic Skin changes
venous insufficiency s/s
Progressive Pitting Edema Secondary skin changes: Edema (pitting) Fibrosis Hyperpigmentation-Hemosiderin deposition Thickening of the subcutaneous tissue Pruritis Ulceration Impaired wound healing decreased sensation lack of hair
dusky appearance, dec. sensation, cooler NOT cellulitis (would be warm)
venous insufficiency tx
Fitted Graduated Compression Stockings
Avoidance of long periods of time sitting/standing
Intermittent elevation
