Vascular System

Question 1

Atherosclerosis

Answer 1

common plaque locations: coronary arteries, carotid bifurcation, proximal ilia arteries, adductor canal region of distal superificial femoral arteries

common sequelae: MI or angina pectoris; TIA or stroke; lower extremity ischemia

Question 2

Aneurysms

Answer 2

true or pseudoaneurysms
most likely in infrarenal aorta, iliac arteries, and popliteal arteries.
increased levels MMP-2 and MMP-9
associated with atherosclerosis.
Features: incidental finding of pulsatile mass, pain, thrombosis, distal embolization, rupture
Dx: PE, US, CT
Tx: >5.5cm in men or 4.5cm in women = surgical repair open or endovascular via graft.
rupture = back pain, hypotension, and pulsatile abdominal mass
Complications = infection, aortoenteric fistula, graft thrombosis, colonic ischemia

Question 3

Endoleaks

Answer 3

"ECHPE"
Type 1 = ends leak
Type 2 = collaterals via lumbar or IMA
Type 3 = holes in graft
Type 4 = porosity, diffusion through the graft
Type 5 = endotension, can't see leak

Question 4

Aortic Dissection

Answer 4

tear of intima into media of aortic wall.
Type A = ascending aorta
Tx: emergent surgery
Type B = descending aorta
Tx: lower BP/HR, decrease velocity of left ventricular contraction
Features: severe tearing chest pain.Dx: double barrelled aorta
Dx: transesophageal echo, CT, angiography

Question 5

PAD

Answer 5

aka peripheral arterial occlusive disease
cause: occlusion or stenosis of arteries of lower extremities
Features: intermittent claudication, ischemic rest pain, skin ulceration, gangrene, loss of hair on distal aspect of leg, muscle atrophy, color changes in leg.
Dx: pulses on exam, Doppler of pulses, ABI <0.9, MRA, CTA
Tx: antiplatelet therapy, beta blocker, percutaneous transluminal angioplasty, balloon stents, atherectomy, endarterectomy for carotid atherosclerosisy, bypass procedures, amputation

Question 6

Dry Gangrene

Answer 6

mummification of digits of foot without associated purulent drainage or cellulitis

Question 7

Wet Gangrene

Answer 7

associated with ongoing infection.

Question 8

Chronic Intestinal Ischemia

Answer 8

cause: occlusion of celiac axis, SMA, IMA.
Features: postprandial abd pain, weight loss
Dx: history, duplex US, CTA, mesneteric angiography, MRA
Tx: mesenteric revascularization, proximal mesenteric artery balloon angioplasty and stenting, endarterectomy, bypass

Question 9

Renovascular HTN

Answer 9

cause: atherosclerosis, fibromuscular dysplasia, trauma
associated with poorly controlled BP, ischemic nephropathy
1. atherosclerosis = proximal part of renal artery
Tx: angioplasty and stenting
2. fibromuscular dysplasia = middle to distal portion of renal artery
Tx: percutaneous transluminal balloon angioplasty
Features: HTN, epigastric or flank bruit
Dx: renal duplex, renal function studies, CTA, MRA, captopril test, catheter renal arteriography
Tx: renal revascularization, surgical bypass

Question 10

Acute Arterial Occlusion

Answer 10

cause: in situ thrombosis, embolus, trauma
sites of embolization: femoral artery, axillary, popliteal, iliac, aortic bifurcation, mesenteric arteries.
Features: pallor, pain, paresthesia, paralysis, pulselessness, poikilothermia
Dx: CT with IV contrast
Tx: anticoagulation, fluid resuscitation, correct acidosis, surgery for thrombectomy or embolectomy if emergent,

Question 11

Systemic Ischemia-Reperfusion Syndrome

Answer 11

Features: compartment syndrome, hyperkalemia, metabolic acidosis, myoglobinuria, renal/pulmonaryinsufficiency.
Tx: hydration, alkalinization of urine, fascial decompression

Question 12

Cerebrovascular Insufficiency

Answer 12

cause: occlusive, ulcerative, or aneurysmal disease of carotid or vertebral arteries.
can cause stroke (CVA)
Features: amaurosis fugax (fleeting blindness), changes in mentation, vision, sensorimotor, permanent neuro deficits if stroke
Dx: CT or MRI
Tx: control risk factors, antiplatelet (asparin, clopidogrel), anticoag (warfarin)

Question 13

Vertebral Basilar Disease

Answer 13

aka subclavian steal syndrome
Features: posterior cerebral and cerebellar ischemia, light-headedness, syncope with arm exercise, supraclavicular bruit, uneven arm BP
Tx: carotid-subclavian bypass, subclavian angioplasty, reimplant subclavian artery into proximal common carotid

Question 14

Superficial Vein Thrombosis

Answer 14

cause: IV catheters, sclerotherapy
Features: swelling, erythema, tenderness
Tx: NSAIDs, warm compresses, excision, thrombectomy

Question 15

DVT

Answer 15

Features: many asymptomatic, local pain from inflammation and edema, unilateral leg swelling, pain with dorsal felxion of foot (Homan’s sign)
Dx: duplex scan, D-dimer, evaluate for protein C/protein S/antithrombin 3/factor V Leiden/prothrombin mutation and anticardiolipin Ab.
Tx: heparin then warfarin for INR 2-3, tPA (for SVA occlusion, subclavian vein thrombosis, acute renal thrombosis), mechanical thrombectomy

Question 16

PE

Answer 16

aka pulmonary embolism
Features: pleuritic chest pain, dyspnea, tachypnea, tachycardia, cough, and hemoptysis, right-sided heart strain on EKG.
Prevention: anticoag in high risk group
Dx: spiral CT with wedge-shaped or lobar defect, pulmonary angiogram
Tx: anticoagulation, IVC filter

Question 17

Varicose Veins

Answer 17

Primary = superficial veins.
cause: incompetence of venous valve at junction of saphenous and femoral vein in inguinal region
Features: heaviness and fatigue after prolonged standing, night cramps, occasionally ankle edema, superficial thrombophlebitis, hemorrhage of superficial veins.
Dx: duplex US
Tx: stripping of saphenous vein, saphenous ligation, radiofrequency ablation, stab phlebotomy

Question 18

Chronic Venous Insufficiency

Answer 18

cause: local venous HTN
Features: swollen legs, hyperpigmentation, venous ulceration in gaiter zone of ankle, lipodermatosclerosis, orange-brown skin at ankle, superficial varicosities.
Dx: venous duplex US, MRI/MRV, CT venogram
Tx: compression stockings, wound care, springing/removal/RFA/laser of superficial veins, interruption of perforating veins, STSG

Question 19

AVM and AVF

Answer 19

aka arteriovenous malformation or fistula
AVM is congenital
Features: thrill and bruit over site, hyperpigmentation, mass, swelling, pain, musculoskeletal disability
Dx: MRI, MRA, CTA
Tx: surgical excision

AVF is acquired, sometimes for dialysis.
associated with pseudoaneurysms
Features: thrill and bruit
Dx: duplex US
Tx: surgical repair.

Question 20

Raynaud syndrome

Answer 20

cause: cold or emotionally induced episodic digital ischemia
Features: female, 50% with autoimmune disease (scleroderma, lupus, etc).
3 phases:
1. white = profound vasospasm causes blanching
2. blue = cyanosis after 15 min from delayed venous emptying
3. red = when flow restored.
Dx: history, phsical, confirm autoimmune disease, doppler
Tx: discontinue ergotamines and beta blockers, use CCBs and alpha blockers, xylocaine

Question 21

Thoracic Outlet Syndrome

Answer 21

cause: compression of brachial plexus, arteries, veins, elongated transverse process of 7th cervical vertebra, cervical rib, marrowed costoclavicular space.
Features: young and middle aged women, paresthesias of arm and hand, cold arm, pallor, muscle fatigue, subclavian aneurysm.
Dx: history, Adson’s test (radial pulse disappears on arm abduction and external rotation), cervical xray, nerve conduction velocity
Tx: PT, botox, surgical decompression

Question 22

Lymphedema

Answer 22

Primary = congenital (birth), lymphedema praecox (10-15hr), lypmhedema tarda (after 35yr)
Secondary = from infection, radiation, surgery, neoplastic invasion
Features: diffuse painless extremity enlargement, pitting to woody edema
Tx: compression devices, foot care, abx, elevation, bed rest if infection, surgery if fails (lymphangioplasty or excision)
Increased risk of lymphangiosarcoma