Vascular Disease, Disease of the Aorta, and Peripheral Vascular Disease - part 2

Question 1

Risk factors for Aortic Dissection

Answer 1

• Long-standing arterial HTN
• smoking, dyslipidemia, cocaine
• Hereditary vascular conditions
• Vascular inflammation
• Deceleration trauma
• Iatrogenic factors

Question 2

Pathophysiology of aortic dissection

Answer 2

Intimal tear leads to penetration of blood within the aortic wall

False lumen forms separating layers of aortic wall

Question 3

What is the most direct and useful classification criteria for aortic dissection?

Answer 3

Sanford classification

Question 4

How does the sanford classification classify aortic dissection?

Answer 4

Type A: Always involves the proximal aorta

Type B: NO proximal involvement at all (descending aorta dissection only)

Question 5

Common presenting symptoms of Type A aortic dissections

Answer 5

Can be none

Pain, numbness, TIA, stroke

Symptoms related to compression of the adjacent tissue such as chest pain, dyspnea, hoarseness, dysphagia, CHF, aortic insufficiency, head and neck swelling

Question 6

Complications of Type A aortic dissections

Answer 6

• Aortic rupture
  
  • –rupture into pericardium, pleura, or peritoneal cavity
• Cerebral ischemia
• Pericardial tamponade
• Acute aortic regurg leading to pulmonary edema
  
  • –disruption of aortic annulus
• Coronary insufficiency

Question 7

General/Classic clinical presentation of an aortic dissection

Answer 7

Abrupt onset of severe pain in chest or back

Classically described as ‘ripping,’ ‘tearing,’ or migrating

Focal neurologic deficits if dissection extends into cerebral vessels

Syncope

Question 8

Aortic dissection physical exam findings

Answer 8

Unequal upper extremitiy BPs
Tachycardia
Pulse deficits
Focal neurological deficits
Aortic insufficiency (acute)
Evidence of pericardial tamponade

Question 9

Radiographic findings of aortic dissection

-which are most common?

Answer 9

Normal
Widen mediastinum **
Abn cardiac contour
Abn aortic contour **
Pleural effusion
Absence of wide mediastinum

** = most common

Question 10

Acute aortic dissection therapy/tx

Answer 10

Establish B-blockade
Calcium channel
Vasodilate if BP remains elevated after adequate B-block
Adequate analgeis
Low threshold for intubation if unstable
DO NOT GIVE FIBRINOLYTICS

See notes for differences b/t Type A and B

Question 11

Type B dissections can be considered unstable. What would make them classified as this?

Answer 11

Propagation with compromise of downstream vasculature

Impending rupture

Unrelieved pain

Question 12

Do we do surgery for aortic dissection?

Answer 12

If type A, emergent surgery is definitive treatment

If type B, reserve surgery for complications. Prefer medical therapy if patient is stable.

Question 13

Chronic aortic occlusions

• chronic meaning..
• locations
• symptoms
• physical exam

Answer 13

Progressive narrowing of distal aorta

From rentals to iliac arteries but also in the great vessels

SXs: claudication of low back, buttocks, impotence or none

Absent pulses below obstruction, bruit, skin/hair changes, redness on dependency

Question 14

Acute aortic occlusion

• how does it come about
• what does it cause/symptoms
• physical exam

Answer 14

If distal aorta - MEDICAL EMERGENCY

Pre-existing narrowing of plaque and rupture
Acute ischemia of lower extremities
Pain with rest
Pallor
Absent pulses

Question 15

Aortitis can cause…

Answer 15

aneurysms and dissections

see the notes for more on aoritits
-its part of the vasculitis diseases studied previously

Question 16

Aortic coarctation

Answer 16

Congenital stenosis within aorta (usually by ligamentum arteriosum)

Strongly associated with bicuspid aortic valve

Question 17

What is peripheral arterial disease (PAD)?

Answer 17

Disease of the arterial tree beyond the heart

Arterial disease is either “blockage or blowout”

Question 18

Acute PAD results from ..

Risk factors…

Answer 18

embolic sources

Risk factors

• turbulence at bifurcations
• arteriolar narrowing
• trauma
• hyper-coag states and polycythemia

ACUTE PAD IS A MEDICAL EMERGENCY

Question 19

Chronic PAD of lower extremities has a high association with …

Answer 19

cerebral vascular and heart disease

Question 20

What are the primary sites of PAD?

Answer 20

Femoral and popliteal (80-90% of symptomatic patients)

Tibial and perineal (40-50%)

Abdominal and iliac (30%)

Question 21

Hallmark symptom of lower extremity PAD

Reproducible in terms of …?

Answer 21

Hallmark: Claudication

Reproducible in terms of:

• effort
• location
• examination

Question 22

Claudication

Answer 22

Effort related cramping, pain, or weakness in a mm group that occurs after a reproducible amount of effort

Symptoms occur one joint level distal to the point of obstruction

Question 23

Spectrum of lower extremity PAD (i.e. what is the progression like in terms of symptoms)

Answer 23

Asymptomatic
Claudication
Rest pain
Numbness, tingling, lack of sensation
Ulceration and gangrene

Question 24

What are some signs of chronic PAD?

Answer 24

Decreased or absent pulses distal to obstruction

Bruits heard over narrowed artery

Mm atrophy and weakness with exercise

Skin texture (thin and shiny) and color changes (cool, pale, blue) and hair loss

Question 25

Consequences of DVT can be severe. What are some examples of this?

Answer 25

Pulmonary embolism

Death

Chronic venous stasis - swelling, pain, redness, cyanosis/hypoxia, ulcers (wet looking)

Calf pain especially with weight bearing or pressure on calf

Question 26

D-dimer

• what is it measuring?
• specific or sensitive for deep vein PVD

Answer 26

D-Dimer (degradation product of fibrin) - sensitive but not specific