Vascular Medicine Interventions

Question 1

PAD is not just a marker of atherosclerosis and its associated conditions, but has a been proven to be a powerful ____ _____of adverse events.

Answer 1

independent predictor of adverse events;

Question 2

3. Discuss why treatment is so important based vascular disease morbidity

Answer 2

vascular disease relates to a serious reduction in the quality of life and tx. can address serious concerns like claudication

Question 3

7. Describe three strategies for surgical revascularization

Answer 3

1. bypass
2. endarterectomy: surgical excision and removal of arterial plaque
3. embolectomy: removal of arterial or venous thrombus, often formed in hybrid surgical/endovascular fashion

Question 4

7. Describe four different strategies for endovascular therapy.

Answer 4

angioplasty: ballon catheter to dilated artery
atherectomy: different catheters are used int eh removal of arterial plaques
stenting: in addition to atherectomy or angioplasty to increase short-term safety and long term potency
filters: endovascular devices designed to prevent embolization of plaque or thrombus

Question 5

Why is PAD considered under diagnosed and treated?

Answer 5

only 10% present with typical claudication, 40% are “asymptomatic” may have adapted lifestyle without recognizing limitations— in this case it important to ask specific questions about level of activity

Question 6

5. What is considered first line treatment for aortoilliac occlusive disease?

Answer 6

surgery is effective but can be high risk, endovascular therapies are the first line

Question 7

8. What is the presentation and cause of critical limb ischemia? How can this be distinguished from acute limb ischemia?

Answer 7

presentation is rest pain in the lower leg or foot or tissue loss due to ulceration (usually located on the feet: heels, tips of toes, between toes), gangrene etc., usually preceded by claudication (differential);

primary cause is chronic atherosclerotic stenosis and or occlusion

distinguished from acute limb ischemia by the 6P’s- parethisias, paralysis etc. (usually cardio- or atheroembolic)

Question 8

Why is prognosis poor for patients with critical limb ischemia?

Answer 8

arterial obstructions are diffuse so the risk of concurrent cardiac, cerebrovascular, renal and pulmonary co-morbidities is high (ie. 50% of all below the knee amputation patients do not survive beyond 5 years

Question 9

Discuss the elements of medical therapy and revascularization treatment of limb ischemia management.

Answer 9

medical therapy: wound care, risk factor modification

revascularization to restore adequate perfusion, reduce/eliminate pain and help wound healing to salvage limbs

Question 10

Would it be reasonable to chose bypass or angioplasty in severe ischemia of the leg?

Answer 10

they have approximately comparable outcomes and surgery is 3x more costly with longer hospital stays

Question 11

What are two additional causes for renal artery stenosis besides atherosclerosis or fibromuscular dysplasia?

Answer 11

vasculatitis: Takayasu’s or Polyarteritis Nodosa

Question 12

Renal artery stenosis is associated with HTN, ESRD and PAD how?

Answer 12

renal artery stenosis occurs in 5% of HTN patients, it is the 3rd leading cause of ESRD and its presence is correlated with severity of PAD

may present with CHF or unstable angina due to the increase in plasma volume

Question 13

Stratify the treatment based on the degree of progression of RAS.

Answer 13

first line: medical therapy- BP esp
revascularization, balloon angioplasty is the first line treatment, angioplasty and stenting is reserved for global renal ischemia or severe refractory hypertension

Question 14

What are the leading causes of upper extremity DVT?

Answer 14

usually catheter related (PICC line, central line or pacemaker leads)

Question 15

What is the primary presentation of DVT?

Answer 15

pain, marked edema, diminished distal arterial pulses, and blanching; can eventually result in incompetent valvular system, and venous hypertension

Question 16

What is phlegmasia cerulean doles?

Answer 16

cyanosis from DVT associated with malignancy causing a painful blue leg, with marked edema

Question 17

How is DVT thrombus burden related to valvular function?

Answer 17

there is a direct relationship between the speed of thrombus elimination and preservation of value function, higher speed, higher valve function; delayed thrombus elimination leads to greater inflammatory response, fibrosis and valvular damage

Question 18

What is the pathophysiology and symptoms of post thrombotic syndrome?

Answer 18

caused by ambulatory venous hypertension, valvular incompetence and venous insufficiency leading to: edema, chronic pain, hyper pigmentation, stasis and venous ulceration

Question 19

Discuss elements of DVT prophylaxis

Answer 19

anticoagulation
compression stockings
IVC filter placement (important that patients may have a PE while unfractioned heparin is being adjusted)
thrombolysis treatment (not clot propagation can occur despite adequate anticoagulation)

Question 20

What factors would lead to IVC filter placement? (indications)

Answer 20

massive DVT with residual DVT
proximal DVT and or PE
inability to take anticoagulation
strongly consider temporary IVC filters as first choice

Question 21

What is Pharmaco-Mechical Thrombolysis (PMT)?

Answer 21

catheter-directed thrombolysis allows for selective delivery of thrombolytic therapy as well as adjunctive mechanical therapy (removal of thrombus)

therapies include: rheolytic therapy (clot fragmentation and then removal, trellis-8 (single setting thrombolysis) or use of ultrasound to break up clots for thrombolytic agent

Question 22

What symptoms would a patient with carotid stenosis present with?

Answer 22

1. asymptomatic
2. bruits
3. amaurosis fugal (embolism to eye)
4. transient ischemic attack
5. stroke

Question 23

Discuss different medical and revasularization techniques for carotid stenosis management, the 3rd leading cause of death in the U.S.

Answer 23

medical therapy: stop smoking, control HTN and DM, use of aspirin or clopidogrel and lipid lowering therapy

carotid endarterectomy and carotid stenting

Question 24

What is a carotid endarterectomy?

Answer 24

surgical removal of the inner layer of the carotid artery when narrowed by atheromatous intimal plaques (often sown up with a patch)

Question 25

Describe treatment of asymptomatic vs. symptomatic patients with endarterectomy?

Answer 25

with asymptomatic, most likely to work with medical therapy, while benefit more significant for people who are symptomatic

Question 26

Carotid stunting is usually paired with which other intervention?

Answer 26

endovascular stunting of carotid artery with implantation of self expanding stent

Question 27

Discuss the use of stenting v surgery in patients with carotid stenosis.

Answer 27

stenting has less risk of MI but long-term outcomes are really equivalent, carotid endectomy is still the gold standard