Vascular Disease Flashcards
3 layers to wall of artery
adventitia
media
intima
what is atherosclerosis
deposition of fat in the walls of the artery underneath the intima
peripheral arterial occlusive disease risk factors
age over 40 greater in men hyperlipidemia smoking HTN Diabetes Obesity
Signs and symptoms of peripheral arterial occlusive disease
intermittent claudication loss of hair thinning of skin cyanosis or pallor cool to touch arterial ulcer dependent rubor DIMINSHED OR ABSENT PULSE SOUNDS
what is intermittent claudication?
pain in legs when walking, muscles distal to lesion/plaque is what is symptomatic.
ex: plaque in femoral artery causes cramping in calves
peripheral arterial occlusive disease diagnosis
physical exam of peripheral pulse by diagnostic testing:
- ankle- brachial index
- US
- CT angiogram
- MR angiogram
- Angiography
what is gold standard diagnosis for peripheral arterial occlusive disease
angiography
easiest/ fastest/ least invasive diagnostic test for peripheral arterial occlusive disease
ANKLE BRACHIAL INDEX
When is an MR angiogram likely to be done in diagnosing a pt with peripheral arterial occlusive disease
when they can’t handle CT contrast
peripheral arterial occlusive disease treatment
CONSERVATIVE CARE:
- WALKING PROGRAM
- RISK FACTOR MODIFICATION: quit smoking, control cholesterol, diabetes, etc.
- Medications: antiplatelt (aspirin 81 mg), cilostazol (symptom relief- HF its can’t take this)
Endovascular revascularizaton
open arterial bypass
(fem-pop MC)
CRITICAL LIMB ISCHEMIA- 6 symptoms/ things to know
- Dry gangrene- black toe, mummified
- Wet gangrene- oozy, can get septic
- patients with rest pain- patient lay flat and have pain in distal part of foot, when they walk it improves- “sleep in recliner”
- 5 P’s- pulselessness, paresthesia, paralysis, pain, pallor
- patients with rest pain require urgent revascularization as well as tissue debridement
- may result in amputation
when to do routine referral for peripheral arterial occlusive disease
intermittent claudication with failure to respond to conservative measures (walking program)
diminished pulses
when to do urgent referral for peripheral arterial occlusive disease
arterial ulcers
gangrene
when to do emergent referral for peripheral arterial occlusive disease
suspicion of acute thrombus/embolus
5 P’s
when does arterial thrombosis occur?
when the intact intimater plaque ruptures and you get platelets that stick to fatty layer
what is a collection of platelets called?
thrombosis
difference between thrombus and embolus?
thrombus is at site where intimacy ruptured
embolus is when piece of thrombus breaks off and travels somewhere else
signs and symptoms of arterial thrombus and embolism
pain at site of infracted organ
end organ dysfunction
evaluation for arterial thrombus and embolism
- EKG
- Echo
- imaging of other potential sources where thrombus may have originated- angiogram, US
treatment of arterial thrombus and embolism
- immediate anticoagulation
- endovascular intervention (thrombolytics: pharm-TPA, or mechanical)
- open thrombectomy
- bypass for distal flow restoration
aortic aneurysm etiology
- uncontrolled HTN= MCC
- atherosclerosis
- connective tissue disorders
- infection- microtic aneurysm
- traumatic aneurysm- very uncommon
signs and symptoms of aortic aneurysm
most are asymptomatic
abdominal pain–> suspect ruptured AA
Bruit
Palpable abdominal mass (pulsatile)
aortic aneurysm Diagnosis
- US
2. CTA,MRA, Angiogram
when is the wall of artery considered aneurysmal?
when it gets to 4cm
what is a mural thrombus
thrombus stuck to wall of aneurysm- has much smaller risk of embolization
aortic aneurysm treatment
- watchful waiting
- smoking cessation
- endovascular stenting
- open/laproscopic repair
what size do you generally fix anuerysms
5 1/2 cm
what is aortic aneurysm?
ballooning out of section of aorta
when to do routine referral for aortic aneurysm
palpable abdominal mass
aneurysm measuring less than 5 cm
when to do emergent referral for aortic aneurysm
suspicion of rupture
what is a retroperitoneal rupture in aortic aneurysm ?
outside peritoneum, patients are more likely to survive
usually some structure will tamponade off bleeding
what is a intraperitoneal rupture in aortic aneurysm ?
inside peritoneum, can put entire blood volume in peritoneum. these patients die very quickly.
percentage of patients that survive a ruptures AA
25%
pseudo aneurysm etiology
arterial puncture (heart Cath) arterial bypass anastomosis
what is a pseudo aneurysm
there is hole in artery somewhere and you have flow outside blood vessel but in general it is tamponade off by surrounding structures. generally we see in groin (pulsatile mass)
pseudo aneurysm signs and symptoms
pain
swelling
ecchymosis
pseudo aneurysm diagnosis
US
pseudo aneurysm treatment
- inject thrombin into pseudo aneurysm
2. manual pressure on groin after cath
What is an aortic dissection
tear in intima, you get blood flow in false lumen
risk factors for aortic dissection
connective tissue disorders, trauma
aortic dissection symptoms
chest pain
syncope
dyspnea
compression of surrounding structures
aortic dissection physical exam
hyper/hypotension
lower extremity paralysis, 5 P’s
diminished peripheral pulses
in in aortic root, can get diastolic murmur
diagnosis of aortic dissection
EKG
Chest X ray- widened mediastinum
CT scan
treatment for aortic dissection
manage hyper/hypotension
manage pain
admit to ICU
surgical correction versus management
-in stanford A aortic dissection do surgical management
-in stanfordB aortic dissection do medical management
in the Aortic dissection class Stanford A, what does that mean?
involves ascending aorta and/or aortic arch, and possibly descending aorta
in the Aortic dissection class Stanford B, what does that mean?
involves the descending aorta, without involvement of the aortic are or ascending aorta
Polymyalgia Rheumatica (4)
involves proximal joint pain
no weakness
fever, malaise, weight loss
elevated ESR
what is giant cell arteritis?
systemic arteries affecting medium to large vessels, inflammation in wall of artery
giant cell arteritis symptoms
HA
Jaw caludication
amaurosis fugal
scalp tenderness
giant cell arteritis physical exam
diminished pulses
temporal artery may be nodular, prominent, or pulseless
pale and swollen optic dish on fundoycopic exam
decreased proximal joins range of motion secondary to pain
giant cell arteritis diagnosis
ESR greater than 50
increased C reactive protein
temporal artery biopsy
treatment for giant cell arteritis
high dose corticosteroids- saves vision
aspirin therapy
treatment for polymyalgia rhematica
low dose corticosteroids
may add methotrexate to help taper off steroids
when to refer urgently for polymyalgia rhematica or giant cell arteritis
suspicion of giant cell arteritis
suspicion of polymyalgia rheumatica
refer only after initiation of corticosteroids
when to refer emergently for polymyalgia rhematica or giant cell arteritis
suspicion of giant cell arteritis in presence of vision loss
Deep Vein Thrombosis risk factors
prothrombotic states:
- factor V leiden
- prothrombin mutation
- Protein C or S deficiency
- antithrombin deficiency
other predisposing factors:
- cancer
- pregnancy
- post menopausal hormone replacement
- birth control use
- cigarrete smoking
- surgery
- trauma
Virchow’s triad risk factors for DVT
- venous stasis\
- endothelial damage
- hypercoagulability
Clinical evaluation of Deep Vein Thrombosis
swelling- usually unilateral extremity pain extremity tenderness discoloration homan's sign
what is homan’s sign?
passive dorsiflexion of foot eliciting pain in calf
diagnosis of DVT
- D-dimer
- venous US- MC (look for winking of vein, if there is no winking then think thrombosis)
- venography- active picture done with c arm and IV contrast–> looking for lack of contrast filling
Deep Vein Thrombosis treatment
- anticoagulation
- unfractionated or low molecular weight heparin
- oral anticoagulation
- novel anticoagulation-n dabigatran, rivaroxaban, apixaban - compression therapy
- catheter directed thrombolysis
- mechanical thrombolysis
- open thrombectomy
- IVC filter
when do you not need to refer for Deep Vein Thrombosis
when dVT is managed with oral anticoagulation and compression stockings
when do you routine refer for Deep Vein Thrombosis
development of post-phlebitic syndrome
phlebitis: warmth, erythema, palpable cord
when do you emergently refer for Deep Vein Thrombosis
suspicion of proximal DVT that may benefit from thrombolysis
when would you admit for Deep Vein Thrombosis
suspicion of PE
superficial thrombophlebitis etiology
- venous catheterization (by us inserting IV into patient)
- pregnancy
- varicose veins
- trousseau’s thrombophlebitis–> abdominal cance process
signs and symptoms of superficial thrombophlebitis`
redness
tenderness
palpable cord
(Phlebitis)
treatment of superficial thrombophlebitis
NSAIDS- treatment of choice warm compress for pain management gentle massage anti coagulation venous ligation
when to urgently refer for superficial thrombophlebitis
suspicion of thrombus propagation
venous insufficiency or varicose veins etiology
venous thrombosis (DVT) valvular incompetence- valves are damaged
signs and symptoms of venous insufficiency or varicose veins
aching or heaviness sweilling varicose veins (for VI) ulcerations cellulitis
physical exam for venous insufficiency or varicose veins
low extremity edema varicose veins lipodermatosclerosis- firm skin venous stasis dermatitis ulceration--> poorly defined, usually around ankle
diagnosis for venous insufficiency or varicose veins
US
treatment for venous insufficiency or varicose veins
graduated compression socks--> treatment of choice superficial vein ablation perforator vein ligation vein stripping valvular reconstruction
routine referral for venous insufficiency or varicose veins
cosmetic varicose vein concerns
swelling and leg heaviness not helped by compression stockings
venous ulceration
emergent referral for venous insufficiency or varicose veins
infected venous ulceration with sepsis
