Cardiology 2 - Peripheral Vascular Disease

What are the conditions that can coexist with PAD?

- CAD

- A fib

- CVD

- renal disease

Vascular disease may manifest ___ when thrombi, emboli or trauma compromise perfusion

acutely

Which arteries are most commonly affected by peripheral artery disease?

Lower extremity and aorta

PAD rarely exhibits a(n) ___ onset

acute

A history of claudication, resting pain or ulceration suggests ___ of existing PAD

thrombosis

What is the most common cause of sudden ischemia?

emboli (mostly of cardiac origin)

Where is the most common site that emboli will lodge?

femoral artery bifurcation

What determines the severity of an acute manifestation of PAD?

- site

- presence of collateral circulation

- nature of occlusion

Emboli tend to carry higher ___ because the extremity has not had time to develop collateral circulation

emboli

Classic presentation of arterial occlusive disease?

- 50-60 year old male

- (+) hx of smoking

- HTN/hyperlipidemia

- intermitten claudication

- bruit

- decreased or absent distal pulses

Major risk factors for arterial occlusive disease?

- smoking

- hyperlipidemia

- DM

- hyperviscosity

What are some s/sx of arterial occlusive disease?

- intermittent claudication

- hair loss/skin thinning/nail changes

- decreases pulses and bruit

- ulceration and gangrene

- erectile dysfunction

- dependent rubor, blanching with elevation

- pain when 'dependent'

___ may be the sole manifestation of early PAD

intermittent claudication

In ___ symptoms are precipitated by walking a predictable distance and are relieved by resting

PAD

What is the triad of leriche syndrome?

- decreased femoral pulses

- claudication

- impotence

What tests should be ordered for suspected arterial occlusive disease?

- CBC

- CMP

- Lipid profile

- coag studies

- CTA

- MRA

- angiography

(imaging only done with conservative strategies are failing)

Conservative treatments for arterial occlusive disease?

- smoking cessation

- weight loss/exercise

- control of HTN and DM

- atorvastatin

- aspirin/clopidogrel

- PDE inhibitor (pletal - helps with claudication)

Surgical options for PAD?

- bypass grafting

- thromboendarterectomy

- endovascular revascularization

Patients with PAD often have coexistent ___ disease

coronary and/or cerebrovascular (25-40% 5 year mortality rate)

What are the 5 P's of acute arterial occlusion?

- pain (increases with elevation)

- pulselessness

- palor

- paresthesia

- paralysis

M/C area that acute arterial occlusion will occur?

Lower extremities

Management of acute arterial occlusion?

- ABC's, start an IV

- baseline EKG and CXR

- heparin infusion

- consult vascular surgery

- aggressive anticoagulation

Transient symptoms of occlusive cerebrovascular disease commonly arise from small ___

emboli

___ is the modality of choice for detecting and grading the degree of stenosis at the carotid bifurcation

duplex ultrasound

In occlusive cerebrovascular disease, what degree of stenosis establishes a need for revascularization?

- 50% in a symptomatic patient

- 60% in an asymptomatic patient

Tx for occlusive cerebrovascular disease?

- Carotid endarterectomy (gold standard)

- carotid stenting (lower risk of heart attack, higher risk of stroke compared to CEA)

Most cases of mesenteric ischemia occur ___

acutely

Sudden onset severe pain out of proportion to physical exam in the abdominal area

mesenteric ischemia

Lactic acidosis, hyperkalemia and hemoconcentration are late findings of ___

mesenteric ischemia

S/Sx of ___ include fear of eating, weight loss, and 'intestinal angina'

Chronic mesenteric ischemia

___ can contribute to hypertension or ischemic nephropathy

Chronic renal artery stenosis

Which class of drug may cause acute decline in renal function if they have bilateral renal artery stenosis?

ACEi (due to efferent arteriole vasodilation)

Which diagnosis may cause post prandial pain?

acute mesenteric vein occlusion

Tx of acute mesenteric vein occlusion?

thrombolysis and long term-anticoagulation

Which populations are most at risk for developing buerger disease?

- male

- tobacco

- less than 40 y/o

What is the etiology of buerger disease

Unknown (non-atherosclerotic)

Tx of burger disease?

- smoking cessation

Which types of patients typically present with abdominal aortic aneurysms?

- ~55 years old

- male

- hx of smoking

- sometimes found incidentally

At what size to we begin to worry about abdominal aortic aneurysms?

>5 cm

At what time do abdominal aortic aneurysms need to be re-evaluated?

- <4cm = every 2 years

- ~5cm = abdominal US every 6 months

- >5.5cm/grows >0.5cm

Patient presents with mid-abdominal pain that radiates towards the back and states it is a 'tearing' type of discomfort

Abdominal aortic aneurysm

When a patient has a known AAA, is hypertension or hypotension more worrying?

hypotension - active bleeding = increased mortality

Where are most AAA found?

below the renal arteries

Over what size is considered an AAA?

>3cm

Which type of diagnostic studies should be ordered for a suspected AAA?

plain radiographs, US, CAT scan w/ IV contrast

Which diagnostic test is preferred for identification of an AAA?

ultrasound

Which diagnostic test is preferred for evaluation of diameter of AAA?

Cat scan w/ IV contrast

If AAA is larger than 5.5cm or expands by >5mm in 6 months, what is the tx?

- elective repair

- open repair is higher risk

- EVAR (lower risk - needs monitoring)

Patients with AAA that have ___ require urgent operative repair.

symptoms

Most thoracic aortic aneurysms are ___ and caused by ___

asymptomatic, atherosclerosis

Patient presents with chest pain radiating to the back, syncope, HTN, cough, dysphagia and hoarseness

Thoracic aortic aneurysm

What diagnostic tests should be ordered for a suspected thoracic aneurysm?

- EKG (LVH)

- CXR (widened superior mediastinum)

- CAT scan w/ contrast (TEST OF CHOICE)

Descending thoracic aortic aneurysm of ___ or larger are generally considered appropriate for surgical repair

6cm or larger

A spontaneous intimal tear develops and allows leakage of blood into the media of the aorta

aortic dissection

Patient presents with 'sharp, ripping pain' radiating to the back. Patient is diaphoretic, anxious, uncomfortable and has an aortic regurgitation. What is likely diagnosis?

aortic dissection

If aortic dissection is suspected, aggressive measures to ___ are needed

lower BP

Tx for aortic dissection?

- beta blockers (1st line - labetalol)

- second line CCB IV (nicardipine)

- surgical tx

Where are most peripheral aneurysms found?

Popliteal (usually asymptomatic)

Which modality is used to diagnose peripheral aneurysms?

duplex color ultrasound

clinical findings of ___ include progressive lower extremity edema, changes in skin pigmentation, subcutaneous lipodermatosclerosis, and ulcerations.

Chronic venous insufficiency

Tx of chronic venous insufficiency?

- prevention of underlying conditions

- compression stockings

- leg elevation

- avoid prolonged sitting and standing

Are varicose veins typically symptomatic?

- commonly asymptomatic

- aching discomfort, edema, ulcers, and skin hyperpigmentation are possible

In varicose veins, does the severity of symptoms correlate with the number/size of varicosities?

No

In every patient with varicose veins, they should be evaluated for ___

occlusive arterial disease

Tx of varicose veins?

- non-surgical (compression stocking and sclerotherapy)

- surgical (phlebotomy and endovenous ablation)

what is an erythematous indurated vein called?

superficial venous thrombophlebitis

What are the most common etiologies of superficial venous thrombophlebitis?

- IV catheter

- spontaneous

- trauma

- varicose veins

- DVT

- pregnant or postpartum women

- not an infection

Tx for superficial venous thrombophlebitis?

- moist heat

- NSAID

- limb elevation

- watch for septic thrombophlebitis

Deep vein thrombosis is associated with which complication?

Pulmonary embolism

What are the risk factors of a DVT?

- immobilization

- general surgery

- active malignancy

- OC use

- smoking

- obesity

- pregnancy

- elderly

80% of DVT's arise from the ___

deep veins in the calf

What are the s/sx of DVT?

edema, thigh discomfort, tenderness, erythema and warmth. Some may be asymptomatic

What is Homan's sign?

calf pain on dorsiflexion of foot (DVT diagnostic)

Right iliac artery compresses left iliac vein where they cross and causes a left sided DVT

May-Thurner syndrome

Prevention of DVT?

- elevate head of bed

- compression stockings

- early ambulation

Tx of DVT?

- heparin, LMWH, warfarin, novel oral anticoags

- inferior vena cava filter

An abnormal collection of protein-rich fluid in the interstitium

Lymphedema

Lymphedema begins as non-tender pitting edema but with time becomes ___

non-pitting edema

Tx of lymphedema?

- Pharmacologic (benzopyrones, retinoid-like agents, anthelminthic agents, antibiotics)

- non-pharmacologic (maintain hygiene, physical therapy/compression stockings, weight loss, avoid trauma, elevate effected limb)

___ is defined as an inflammation of the lymphatic channels that occur as a result of infection at a site distal to the channel

Lymphangitis

What is the most common cause of lymphangitis?

GABHS

What are two important ddx for nodular lymphangitis?

- sporotrichosis

- mycobacterium marinum

Work-up for suspected lymphadenitis?

- CBC

- blood culture

- I&D if abscess present

Tx of lymphadenitis?

- consider hospital admission

- analgesics/anti-inflammatories

- hot, moist compresses

- elevate and immobilize

- empiric abx (PCN, keflex)