Vascular Ds Flashcards
Atherosclerotic Peripheral Vascular Disease: Blockage at Aorta & Iliac
Who has increased risk?
30% occurrence in 70 yo without risk factors
30% occurrence in 50 yo with risk factors
Risk factors:
-diabetic
- tobacco use****
- >70 yrs
- MC: white obese male smokers age 50-60 yo
Atherosclerotic Peripheral Vascular Disease: Blockage at Aorta & Iliac description ( what arteries location, progression, mortality)
-Systemic atherosclerotic process
-Lesions in the distal aorta and proximal common iliacs
-Progression may lead to complete occlusion of one of both iliac arteries
-Mortality from the cardiac disease is 25-40% at 5 years
Atherosclerotic Peripheral Vascular Disease: aorta and iliac S&S
⅔ asymptomatic or not classic symptoms
MC: Intermittent Claudication (local muscle pain with movement)
- Pain is secondary to insufficient blood flow when there is an increased demand from exercise
- Starts as CALF cramping → Thigh & Buttock pain → Erectile dysfunction → Pain during rest
- sx are relieved with rest and reproducible with the same exertion! (compare w stable angina)
- pts may dangle foot off bed so gravity helps
- Bruit may be heard over aorta, iliac, or femoral artery (check belly button bruits)
Leriche’s Syndrome:*
- Claudication
- Absent/Decreased Femoral Pulse
- Impotence
Leriche’s Syndrome: what are the signs and what is this associated with
Leriche’s Syndrome:*
- Claudication
- Absent/Decreased Femoral Pulse
- Impotence
Atherosclerotic Peripheral Vascular Disease: aorta and iliac
Atherosclerotic Peripheral Vascular Disease: aorta and iliac work up
Ankle Brachial Index:
- Compares blood pressure in upper limbs vs lower limbs to determine if there is abnormal decreased perfusion
- ABI = BPAnkle / BPArm
- If ABI < 0.9 = Peripheral Artery Disease
- If ABI < 0.4 = Critical Limb Ischemia
-Exaggerated by exercise
-ABI measured using the dorsalis pedis and posterior tibial arteries
CT angiography and MRI:
- identify anatomic location of the lesion
- CT Angiography: cautious with CKD: could damage nephron from contrast
atherosclerotic peripheral vascular disease: aorta and iliac tx medical and risk factor management
- STOP SMOKING! (biggest risk)
- Exercise Program: walking is the best*, optimal weight
-Lipid and HTN management: High dose statin for plaque stabilization
-Plavix daily, High dose statin daily
-Phosphodiesterase inhibitors (Pletal/cilostazol): helps with cramping
-Aspirin: reduces cardiovascular morbidity
atherosclerotic peripheral vascular disease: aorta and iliac tx surgical
Angioplasty and stenting: efficacy - closure/renarrowing in 30-50%!
-Bypass surgery (Axillo-femoral, fem-fem bypass) patency 90% at 5 years
atherosclerotic peripheral vascular disease: femoral and popliteal description
-Usually occurs 10 yrs after aortioiliac disease
-Frequently at the site where the superficial femoral artery passes through the abductor magnus tendon in the distal thigh (adductor hiatus)
-Less common in common femoral and popliteal but these lesions are debilitating
atherosclerotic peripheral vascular disease: femoral and popliteal sx + signs
-Calf cramping
-Rubor (red) of the foot with blanching on elevation (Buerger’s Test)
-Reduced popliteal and pedal pulses (Would NOT have reduced FEMORAL PULSE)
Atrophic changes in the lower leg and foot:
-Loss of hair, thinning of skin & tissue, atrophy of muscle.
-gangrene or ulcers (severe)
- should only have toe nails cut by podiatrist
atherosclerotic peripheral vascular disease: femoral and popliteal work up/dx
Reduced ABI: <0.9
Anatomical Location of Lesion determined by:
- Duplex Doppler ultrasound: do first!
- CT Angiography: CI with renal insufficiency since contrast is processed in kidneys
- MRI
atherosclerotic peripheral vascular disease: femoral and popliteal tx risk factors and medical
-Risk factor reduction
-Exercise Program
Medical therapy same as Aortioiliac:
- High dose Statin daily (Atorvastatin) for plaque stabilization
- Phosphodiesterase Inhibitors
- clopidegrel(plavix) daily
- Aspirin to reduce cardiovascular morbidity
atherosclerotic peripheral vascular disease: femoral and popliteal tx surgical
Femoral- Popliteal Bypass
Angioplasty and stenting (if less than 10 cm):
-1 yr patency 50% angioplasty, 80% stenting
-3 yr restenosis common : <50% pts have patency and have restenosis
Thromboendartectomy:
- for common femoral & profunda femoris -> Where bypass and stenting less successful
atherosclerotic peripheral vascular disease: tibial and pedal description
-Severe pain in the FOOT that is relieved by dependency (using gravity to help blood flow)
-Pain or numbness in the foot with walking (no blood supply)
-Primarily in diabetics: Due to chronic vessel damage from hyperglycemia
- high rates of amputation
TP = FOOT fetish
atherosclerotic peripheral vascular disease: tibial and pedal sx and signs
-May not have claudication symptoms -> usually just pain in the FEET
-Rest pain & Ulcerations: Critical limb ischemia! High rate of amputation
Sx:
-Pedal pulses absent
-Pallor on elevation
-Skin cool, atrophic and hairless
-pt typically awakened with dorsal foot pain -> Pain relieved with dangling foot off bed
artherosclerotic peripheral vascular disease: tibial and pedal work up and tx
ABI low (<0.4 = critical limb ischemia)
Digital subtraction angiography *
MRI and CT NOT as useful with small vessels
Tx:
-Good foot care
-If non-healing ulceration after 2-3 weeks: revascularization to avoid amputation
-Bypass to distal tibial: 70% patent at 3 years.
-Amputation if needed
acute aterial occlusion of limb -Signs and Symptoms
Six P’s:
- Pain
- Pulselessness
- Pallor
- Poikilothermia: Inability to regulate constant body temp
- Paresthesia: can’t feel it
- Paralysis: can’t move it (end stage)
Pain is often localized and less severe when the limb is in the dependant position
-As the ischemia prolongs, paresthesia replaces pain and the final stages of injury cause paralysis*
Livedo reticularis:
- lacy pattern on the skin -> Mottled vascular pattern*
What is acute arterial occulsion of a limb + source/cause of occlusion
-SUDDEN pain in an extremity with an absent extremity pulse*
Source of acute arterial occlusion:
-Cardiac emboli (think AFib)
-thrombosis - endocarditis
- hyper coagulable state: (hormone therapy, cancer, obese, sedentary)
acute arterial occlusion of a limb workup
- Little to no flow on Doppler US
- If suspicious of acute arterial occlusion, STRAIGHT TO THROMBOEMBOLECTOMY (emergency!!!)
-Don’t delay with an MRI or CT, only with low suspicion
acute arterial occlusion of a limb tx
IMMEDIATE REVASCULARIZATION! - Should be within 3 hrs, by 6 hrs irreversible!
IV heparin: prevent clot from getting bigger
Tissue plasminogen activator: TPA - breaks down clot
Thromboembolectomy: clot removal
-10-25% risk of amputation, 25% hospital mortality rate
Occlusive Cerebrovascular Disease definition, causes
Definition:
- blood vessels that supply the brain become narrowed/blocked
Caused by:
- Atherosclerotic Disease in the CAROTIDS
- EMBOLI
- TIA (seconds to minutes): temporary blockage of blood flow to the brain -> reversible event if perfusion is restored, but now higher risk for future stroke..
- stroke (>24h): block of blood flow to brain; ischemic or hemorrhagic
1/4 ischemic strokes come from ____ source. 90% result from a problem in the ______ artery.
1/4 of ischemic strokes come from an ARTERIAL source
90% of these resulting from a problem in the PROXIMAL INTERNAL CAROTID ARTERY
Occlusive Cerebrovascular Disease presentation
Marked by:
- Sudden onset of weakness and numbness of extremities or face
- Aphasia: cannot understand speech
- Dysarthria: difficulty speaking for a few seconds *
- Unilateral blindness (Amaurosis Fugax)*
-Carotid artery bruit: loudest mid neck
occlusive cerebrovascular disease: workup
-Duplex Ultrasound for carotid stenosis
-MRA
-CTA
occlusive cerebrovascular disease: tx
CVA management
If >60% carotid stenosis: INTERVENTION
-Carotid Endartectomy
-Angioplasty and stenting*
-25% will have recurrent CVA if no intervention
If 30-50% stenosis:
- MONITOR and risk factor modification
-F/u with US monitoring
1/4 ischemic stroke=___________ source
arterial source, 90% from proximal internal carotid artery
visceral artery insufficiency definition
Embolus or Thrombus to major mesenteric vessel (SMA, IMA)
-Usually two of three vessels have occlusive disease if symptoms being there is collateral circulation (celiac, SMA, IMA, marginal)
Acute is emboli or thrombus to major mesenteric vessel
- Often pain out of proportion to initial clinical findings -> 10/10 pain with no PE findings
-Low flow state from CHF or hypotension
Chronic:
- adequate at rest but ischemic when flow demands increase after eating
-Severe post prandial abdominal pain
-Weight loss with fear of eating
thromboangitis obliterans/buerger disease definition and presentation
Definition:
-Inflammatory and thrombotic process of the DISTAL most arteries and occasionally the veins.
-vasculitis due to smoking!
Presentation:
-male smoker less than 40 yrs!!!!*
-Severe ischemia of the feet, fingers and hands.
-Pain in distal extremity
- tissue loss and amputation unless they stop smoking
giant cell arteritis definition and presentation
Definition:
-Systemic inflammatory condition of the MEDIUM and LARGE vessels
-Large vessel problems occur in 15% of patients within 7 years
-complication: blindness
Pt presentation:
- MC: older than 50 yrs old with polymyalgia reheumatica (autoimmune ds)
-May have varicella / zoster relationship
-pt complains of unilateral temporal headache, Scalp tenderness, jaw claudication, throat pain, diplopia and elevated inflammatory markers.
What artery does giant cell arteritis involve?
Frequently involves TEMPORAL artery and other branches of the CAROTID artery
giant cell arteritis: workup and tx
Work Up:
-ESR and C-reactive protein elevated
-Temporal artery biopsy
-Temporal US: may show thickening
Treatment:
-High dose prednisone
- low dose Aspirin
peripheral artery aneurysms presentation
Usually silent until critically symptomatic.
-Present as embolization or thrombosis
Presentation:
- asymptomatic/silent
-70% popliteal with 60% bilateral involvement
- 50% of pts also have a AAA
-Pulsatile mass
chronic venous insufficiency definition + common causes/associations
Definition:
-Loss of wall tension in veins causing stasis of venous blood in the lower extremities
- breakdown of leaked Hb from blood into the interstitial space -> hemosiderin depositis -> dark pigmentation
-Prevention is key!
Common causes/associations:
- DVT
- leg injury
- varicose veins: valve dysfunction
chronic venous insufficiency sx + signs
-Progressive pitting edema starting at the ankle followed by skin and subcutaneous changes
-Itching, dull pain with standing
-Ulcerations just above the ankle
-Skin is shiny, thin and atrophic with dark pigment changes
-medial malleolous- more likely to have weeping lesions
-swelling
superior venal caval obstruction
Definition:
-Partial or complete obstruction of the SVC usually secondary to neoplastic or inflammatory process in the superior mediastinum
- MC: lung cancer obstruction
SX:
-Swelling of the neck, face and upper extremities
- Dilated veins over the upper chest and neck
-Bending over or lying down accentuates the symptoms
Dx:
-CT
Tx:
-treat underlying cause
- possible stenting
