Vascular Disease Mayo Flashcards
PAD: Background
- Risk factors: smoking, DM, CAD, age
- Do NOT screen if asymptomatic
- Classic claudication ~10%
PAD: ABI
Highest ankle pressure / highest brachial pressure (right or left)
If borderline, exercise ABI:
- abnormal if ABI decreases by 20%
- abnormal if ankle pressure >30mmHg
PAD: chronic critical limb ischemia
-Symptoms >2 weeks
-Rest pain, ischemic ulcers, gangrene, elevation pallor/dependent rubor
-High risk of amputation
-Tx: early revascularization
Thromboangiitis obliterans
-Buerger’s disease
-M>F, age<40, tobacco use
-Superficial thrombophlebtiis at distal>prox vessels
-Tx smoking cessation, iloprost
Mesenteric ischemia
-Acute arterial->acute abd pain
-Chronic arterial->nausea, weight loss
-Venous thrombus->less abrupt onset
PAD: Treatment
MEDICAL THERAPY
Class 1:
- Statin (also evolocumab-PCSK9)
- Anti-hypertensive (ACEi)
- DM (GLP1, SGLT2)
- Smoking cessation
- Foot care
- COVID/flu vaccines
- Cilastazol if symptomatic (contraindicated in heart failure)
- Anti-thrombotic and/ anti-platelet if symptomatic
Class 2:
- Single agent anti-platelet if asymptomatic
EXERCISE THERAPY
REVASCULARIZATION
PAD: Treatment- antiplatelet, antithrombotic
No recent revasc:
- Single anti-platelet (ASA 75-325mg, Clopidogrel) OR low dose asa + rivaroxaban 2.5mg BID
Recent revasc:
- Low dose asa + rivaroxaban 2.5mg BID
PAD: Revascularization
By location:
- Aortoiliac, femoropopliteal stenosis = endovascular (class 1)
- Common femoral = endarterectomy, endovascular (class 2a)
- Infrapopliteal (Class 2b)
By disease type:
- Chronic limb threatening ischemia (CLTI) = Class 1 to revasucularize
PAD: Acute limb ischemia
Cx: embolus, thrombosis, dissection, trauma
S/S: pallor, pain, paresthesia, paralysis, pulselessness, poikilothermia. Less than 2 weeks.
Tx: heparin infusion, revascularization
AAA: background
Aorta >3cm
Screen with US
Risk factors: first degree fam hx (class 1), smoking history
in men 65-75 (class 1)
AAA: Surveillance US
Indications for repair:
- women >5cm
- men >5.5cm
- 1cm/year
US every 6 months when close to these thresholds
AAA: Management
Blood pressure management
Aspirin
Statin
Smoking cessation
AAA: open surgical vs endovascular repair (EVAR) for infra-renal AAA
Open repair
Pros: fewer complications
Endovascular repair
Pros: fewer procedural mortality, follow up imaging. Cons: endoleaks–>aneurysm can still grow
Acute aortic syndrome: types
- Penetrating atherosclerotic ulcer = penetrates the internal elastic lamina
- Intramural hematoma = hemorrhage within the media
- Aortic dissection = tear in intima with false lumen
Acute aortic syndrome: symptoms
Hemorrhage within the media
Acute aortic syndrome: management
-SBP goal <120mmhg, HR goal 60-80
-Avoid meds with reflex tachycardia (nitros)
-Analgesia
-Surgery?
—Type A goes to surgery
—Type B goes to surgery if persistent pain, propagation, malperfusion of organs
Sporadic aortic aneurysm
Ddx: inflammatory, familial, syndromic, bicuspid
Risk factors: old ago, atherosclerosis, HTN
Management: BP control (beta blocker), lipid control, smoking cessation
Surgery indications:
- 5.5cm or more
- rapid growth >5mm/year
- 4.5cm at time of surgery/CABG
Genetic aortopathy: familial (nonsyndromic)
- Nonsyndromic (phenotypically normal)
- Diagnosed later (50s)
Management:
- Standard medical
- Genetic testing 3-5 yrs
- Screen first degree relatives
- Surgery if aorta >4.5-5.0cm
Genetic aortopathy: Syndromic-Marfan
Syndromic (phenotype)
FBN1. Fibrillin malformed-activates TGFBR–>loss of collagen, elastic tissue
S/S: partial lens dislocation, pectus excavatum, skin striae, scoliosis, arachnodactyly
Management:
- Standard medical
- Genetic testing 3-5 yrs
- Screen first degree relatives
- Surgery if aorta >4.5-5.0cm
Genetic aortopathy: Syndromic-Loey Dietz
Similar mechanism as Marfan, different gene (TGFBR or SMAD). Auto dom
Elevated IgE levels
S/S: abdominal pain, food allergies
Management:
- Standard medical
- Genetic testing 3-5 yrs
- Screen first degree relatives
- Surgery if aorta >4.0cm
- Annual surveillance of vasculature
Genetic aortopathy: Syndromic-Ehlers Danlos
Issue with collagen. Auto dom
S/S: wide space eyes, thin skin (can see vesvels), pretibial scar
Can dissection at normal caliber
Management:
- Standard medical
- Genetic testing 3-5 yrs
- Screen first degree relatives
- Surgery if aorta >4.0cm
- Annual surveillance of vasculature
Genetic aortopathy: Syndromic-Bicuspid
Auto dom
Most common
50-80% develop aortic aneurysm
Turner: short, unable to conceive, ejection click and systolic murmur
Management:
- Standard medical
- Genetic testing 3-5 yrs
- Screen first degree relatives
- Surgery if aorta >5.5cm
- Annual surveillance of vasculature
Inflammatory aortopathy: GCA
GCA>50yr
Arterial wall inflammation
S/S: morning stiffness, fatigue, weight loss, headache, elevated ESR
+PET
50% have aortopathy, 1/3 dissect at low size
Inflammatory aortopathy: Takayasu
Takayasu<50yr
S/S: arm.leg claudication, reduced upper extremity pulses, vascular bruit, carotid abnormality
