Vascular disorders (arterial) Flashcards
What PAD does this indicate:
Pain into thigh/buttocks/groin
ED
Weakness in legs when walking
Extreme limb fatigue
Pain relief with rest and starts again when walking
Leriche’s syndrome = claudication in buttock/thigh, impotence + decreased femoral pulse
aorta-iliac
What PAD does this indicate:
Intermittent claudication confined to thigh + upper ⅓ of calf
Dependent rubor of foot (improvement w/ lifting)
Atrophic changes in lower leg - loss of hair, thinning of skin/subcutaneous tissues, disuse atrophy of muscles
femoral + popliteal
What PAD does this indicate:
1st = Ischemic ulcer or foot gangrene (NO claudication)
Ischemic rest pain confined to dorsum of forefoot, lower calf (relieved with dependency/increased blood flow by gravity)
Does not occur w/ standing, sitting, or dangling
Severe + burning
Awaken from sleep (MC at NIGHT)
atrophic skin changes, non healing wounds
Tibial + pedal
What are risk factors for PAD?
> 70 years old or ~50 w/ risk factors (DM or tobacco use)
What PAD is most common in white men 50-60 who smoke cigarettes?
aorta-iliac
What PAD is most common in black and latino patients, from atherosclerosis ~1 decade after development?
femoral + popliteal
What PAD is most common in diabetic patients, extensive calcification, claudication may not be present?
tibial and pedal
What causes PAD?
atherosclerotic lesions in extremities
What is diagnostic for aorta-iliac + femoral-popliteal?
ABI<.9
What would this PE indicate
PE: Femoral pulses + distal pulses absent or weak with bruits of aorta, iliac, femoral
Dx: ABI <.9, exaggerated by exercise, CTA + MRA (only when symptoms require intervention)
aorta-iliac PAD
What would this PE indicate
PE: Common femoral pulsation normal, popliteal + pedal pulses reduced
Dx: ABI <.9 is diagnostic, <.4 = limb-threatening, duplex ultrasound, CTA and MRA (only if revascularization is planned, but must be monitored)
femoral-popliteal PAD
What would this PE indicate
PE: femoral + popliteal pulses may/may not be present, absent pedal pulses, dependent rubor w/ pallor on elevation, skin of foot - cool, atrophic, hairless
Dx: often ABI <.4, digital subtraction angiography is gold standard, MRA/CTA less helpful
NOT plantar surface burning + not relieved w/ leg dependency
tibial-pedal PAD
What is gold standard in tibial-pedal PAD diagnosis?
digital subtraction angiography
When should you admit an aorta-iliac PAD?
Evidence of chronic limb-threatening ischemia (resting pain + tissue loss)
Acute limb ischemia (needing IV anticoagulation + surgery)
When should you admit a femoral-popliteal PAD?
REFER IF - progressive symptoms, short-distance claudication, rest pain, ulceration
ADMIT IF: chronic limb threatening ischemia or foot infection
When should you admit a tibial-pedal PAD?
ADMIT IF: any patient w/ DM and foot ulcer + infection (emergent I&D) with broad spectrum abx
Lateral
arterial
Medial
venous insufficiency
What is the cornerstone of aorta-iliac PAD treatment?
cardiovascular risk reduction + exercise program
- smoking cessation
- weight loss
How do you treat aorta-iliac PAD?
- antiplatelet therapy (aspirin or clopidogrel)
- low dose rivaroxaban w/ aspirin
- high dose statin
- cilostazol (walking distance improvement)
- endovascular therapy (best for single stenosis)
What is a surgical intervention for aorta-iliac PAD?
Prosthetic aorta-femoral bypass graft (highly effective), graft from axillary artery, contralateral femoral artery graft
What’s first line for a femoral-popliteal PAD?
medical + exercise therapy, risk factor reduction
- antiplatelet therapy (aspirin or clopidogrel)
- low dose rivaroxaban w/ aspirin
- high dose statin
- cilostazol (walking distance improvement)
What’s general treatment for all PAD?
- antiplatelet therapy (aspirin or clopidogrel)
- low dose rivaroxaban w/ aspirin
- high dose statin
- cilostazol (walking distance improvement)
and lifestyle changes
CARS. Cilostazol anti platelet rivaroxavan statin
When should you surgically intervene for a femoral-popliteal PAD?
Progressive claudication, incapacitating, interferes significantly w/ essential daily activities or if pain at rest or ulcers threaten foot
–>
Bypass surgery (femoral-popliteal using autologous saphenous vein)
What are alternative treatments for femoral-popliteal PAD??
Endovascular techniques – angioplasty + stenting in patients undergoing aggressive risk factor modification with smaller lesions
Thomboendarectomy to remove plaque
What’s first line treatment for tibial-pedal PAD?
Prevent ulcers, revascularization to avoid major amputation if ulcer appears + not healing
Bypass + endovascular techniques (saphenous vein)
Amputation
What is Leriche’s syndrome and what is it associated with it?
claudication in buttock/thigh, impotence + decreased femoral pulse
aorta-iliac PAD
What are the 6 Ps of acute arterial occlusion of a limb?
Pain
Pulseless
Pallor
Paresthesia
Paralysis
Poikilothermia
What are symptoms of acute arterial occlusion of a limb?
Sudden onset of extremity pain, loss or reduction in pulses, neurologic dysfunction, pallor, coolness, mottling
What could cause acute arterial occlusion of a limb?
History of claudication
A fib (MC)
What causes acute arterial occlusion of a limb?
Embolism or thrombosis of diseases atherosclerotic segment
>50% from heart → LE, 20% → cerebrum
Pre-existing CAD or PAD + claudication
What could this indicate:
PE: low capillary refill, decreased/absent pulses, cool temperature
acute arterial occlusion of a limb
What diagnostic methods are useful for acute arterial occlusion of a limb?
Duplex US is 1st imaging choice
Doppler + lab = little to no flow in vessels with myoglobinuria + metabolic acidosis
Consider CT angiography
How do you treat first line acute arterial occlusion of a limb?
Immediate revascularization + heparin
What are other ways to treat acute arterial occlusion of a limb?
Endovascular techniques - pharmacomechanical thrombectomy catheters, catheter directed thrombolysis, immediate revascularization
Surgical intervention
What do these symptoms indicate:
Asymptomatic
If symptomatic -
Pain (mild-severe mid abdominal pain radiating to lower back), constant/intermittent, exacerbated by gentle pressure
Rupture = severe pain + HOTN
Abdominal bruit
AAA
What’s the most common cause of AAA?
infrarenal arteries
If AAA is ruptured, what are the key symptoms?
acute abdominal, flank, back pain + abdominal distention + hemodynamic instability
What are risk factors for an AAA?
Males, >55 years, smoking, HTN, atherosclerosis
When is an AAA considered present?
> 3 cm
90% of AAAs are ____ the renal arteries
below
Refer for AAAs diameter is ____
> / 4.5cm
When do you admit for an AAA?
tender aneurysm to palpation, signs of aortic rupture, evidence of infection
What are ways to diagnose AAA?
PE: pulsatile mass on routine PE → order US (unstable) or CT w/ contrast (stable)
What is the test of choice for AAA?
abdominal US
With acute AAA rupture, what may a patient have?
Hct normal, but may have CAD, carotid disease, kidney disease, emphysema
What preemptive screening should you do for AAAs?
1 time screening via ultrasound of men 65-75 years old w/ exposure to 100+ cigarettes, q10 years if 2-2.9cm
How often should you have an US for a 3-3.9cm AAA?
q3 years
How often should you have an US for a 4-4.9cm AAA?
q12 months
How often should you have an US for a 5+cm AAA?
q6 months with contrast
When should you electively repair an AAA?
5.5cm or larger in men or 5 cm in women OR >.5cm in 6 months OR symptomatic
What are other ways to treat AAA?
endovascular repair, underlying cause and surgically (based on size, compression of retroperitoneal structures, pain upon palpitation) –> open surgical aneurysm repair, endovascular aortic repair
What do these symptoms indicate:
Most are asymptomatic, OR substernal back/neck pain, pressure on trachea, esophagus, SVC (dyspnea, stridor, brassy cough, dysphagia, edema in neck/arms, distended neck veins, hoarseness)
TAA
Are AAA ruptures lethal?
no
Are TAA ruptures lethal
yes
What can cause TAA?
atherosclerosis or rarely syphilis, connective tissue disorders
What is the modality of choice for a TAA?
CT scan w/ contrast
When should you refer a TAA patient?
ascending >4.5cm, descending >5cm
What does this CXR indicate:
calcified outline of dilated aorta, widened mediastinum
TAA
How do you treat an ascending aorta TAA?
~5.5cm – open surgery required, repari
How do you treat a descending aorta TAA?
> /5.5cm, endovascular grafting
What are symptoms of PAAs?
6 Ps: Pain
Pulseless
Pallor
Paresthesia
Paralysis
Poikilothermia
and pulsatile mass when in groin
Where is a peripheral artery anuerysm normally?
popliteal artery
Is an anuerysm normal in the femoral artery?
no, not very common, normally a pseudoaneurysm, following punctures for arteriography/cardiac
What are diagnostic tips of peripheral artery aneurysms?
Duplex color US, MRA or CTA, arteriography, abdominal US if found to evaluate for AAA
If prominent or easily felt pulse in popliteal = suggestive + get US
Often bilateral (and many have AAA)
Unequal = PAA
How do you treat PAAs?
Immediate surgery when acute embolization or thrombosis has caused acute ischemia (open surgical bypass)
Indicated when
- Ass w/ peripheral embolization
- >2cm
- Mural thrombus present
How do you treat a pseudoaneurysm femoral artery?
Pseudoaneurysm femoral artery – US compression or thrombin injection
How do you treat a primary femoral aneurysm?
Primary femoral aneurysm - Open surgery w/ prosthetic interposition grafting
What does this characterize:
Severe, persistent chest pain sudden onset that radiates down the back or into anterior chest, possibly into neck
Uncontrolled HTN, syncope, hemiplegia, paralysis of lower extremities, mesenteric ischemia or kidney injury, peripheral pulses diminished/unequal, diastolic murmur
Abdominal pain, neuro findings
aortic dissection
What can predispose someone to aortic dissection?
Pregnancy, bicuspid aortic valve, bovine arch, coarctation, HTN
What are the two types of aortic dissection?
A and B - A revolves around the Arch, and B resolves around the lower part.
No arch = can’t be A
What causes aortic dissection?
Spontaneous intimal tear w/ blood dissecting into media of aorta from repetitive torque, HTN
What could this indicate:
Asymmetric BP
New aortic regurg murmur
EKG: LVH
CXR: abnormal aortic contour or widened superior mediastinum
aortic dissection
What could indicate rupture in an aortic dissection?
HOTN
HTN is most common with Type _ of aortic dissection
B
What imaging is gold standard for an aortic dissection?
multiplanar CT w/ contrast
If a patient is unstable, what diagnostic should you do?
TEE
Admit for aortic dissection if
acute
needing urgent surgical repair (ALL Type A and Type B with malperfusion, rupture, symptoms, uncontrolled BP)
Yearly ____ to monitor aortic dissection development
CT
Aortic dissection is an ____
emergency
How do you treat an acute aortic dissection?
beta blockers (cardioprotective) + BP control (sodium nitroprusside or nicardipine) –> 100-120/60-70
What are additional treatments for aortic dissection?
IV CCBs - nicardipine
Additional - nitroprusside for HTN
Morphine sulfate for pain
Long term BB for HTN
How do you treat a Type A dissection?
urgent, transfer to appropriate facility
How do you treat a Type B w/ malperfusion?
URGENT if aortic branch compromise
How do you treat a Type B w/o malperfusion?
BP control
