Peripheral Vascular Diseases

Aortic aneurysm

A full-thickness dilation of an artery to 1.5+ times its normal diameter commonly involves the abdominal aorta

male, white, smoking, family hx, HTN, atherosclerosis, older age

Risk factors for aortic aneurysm

Loss of elastin and collagen in the media due to inflammatory processes and oxidative stress (more commonly at branch points)

What is the pathophys as to what happens with aortic aneurysms?

abdominal U/S (100% sensitivity)

What is the initial test for AAA?

CT angio (size, anatomy assessment)

What are the pre-operative test for AAA?

MRI, MRA, X rays

What are some other tests for AAA?

Stop smoking, blood pressure control (beta blockers, ACEI), Statins, daily exercise

Managing Aortic aneurysm

open surgical repair (large/complex), EVAR (smaller, accessible)

For AAA larger than 5.5 cm, those with rapid expansion (0.5cm/year), or symptomatic aneurysms - what is the game plan

one time U/S for men 65-75 with hx of smoking, 1st degree relative

What are the screening recommendation for AAA?

U/S, CT

What imaging modalities can be used to monitor small aneurysms (less than 4 cm (biannual), 4.0-5.0 cm (every 6-12 months))

Aortic Dissection

A tear in the intimal lumen that allows blood to enter the media creating a false lumen that can move towards the distal aorta (anterograde) or towards the heart (retrograde)

ascending aorta (emergency)

Standford type A classification involves the

descending aorta (medically managed)

Standford type B classification involves the

Male, older age, HTN, connective tissue disorders, preexisting aortic aneurysm, bicuspid aortic valve, atherosclerosis, smoking, winter months, trauma, iatrogenic injury, coke, meth

Risk factors for Aortic Dissection

aortic rupture, cardiac tamponade, end-organ ischemia (stroke, renal)

Complications of aortic dissection

CT Angio

Patient presents to the ER with severe chest pain which he describes as tearing. On a physical exam you note a diastolic blowing murmur at the RUSB as well as a pulse deficit on the legs. Patient is currently stable. What is the gold standard diagnostic test?

TEE (transesophageal echo)

Patient presents to the ER with severe chest pain which he describes as tearing. On a physical exam you note a diastolic blowing murmur at the RUSB as well as a pulse deficit on the legs. Patient is currently unstable. What diagnostic test do you want to run?

d-dimer (high NPV for rule out), EKG, CXR

Additional tests for aortic disection

emergent surgical repair using open surgical techniques

For Type A dissection, what is the game plan

Beta blocker to target SBP 100-120, morphine for pain, Endovascular repair (TEVAR - if there’s any malperfusion syndrome, rupture, or uncontrolled HTN)

For Type B dissection, what is the game plan

Peripheral artery disease (PAD, peripheral vascular disease (PVD), arteriosclerosis obliterans, critical limb ischemia (CLI), intermittent claudication)

What is a group of chronic atherosclerotic, inflammatory, occlusive, and aneurysmal diseases that cause chronic obstruction of noncoronary and noncerebral arteries - primarily affecting the lower extremities?

smoking, DM, HTN, hypercholesterolemia, CKD, elevated CRP, female, black patients, increasing age

Risk factors for PAD

Asymptomatic, intermittent claudication, rest pain, ulcers, gangrene, leg discomfort not relieved by rest, acute limb ischemia

What are some ways that PAD presents itself

pulses on a doppler

Viable acute limb ischemia

no pulses on a doppler

Threatened acute limb ischemia

no pulses on a doppler, amputation is a must

Irreversible acute limb ischemia

diminished pulses, cool skin, dependent rubor, trophic changes (hair loss), bruits over femoral arteries

What are some physical exam findings that are red flags for PAD

Ankle-brachial index (ABI - abnormal is under 0.90, severe is under 0.5)

What is the 1st line diagnostic test for PAD

duplex u/s, CTA, MRA, digital subtraction angiography

What are some imaging studies we can do for PAD

lipid profile, HbA1c, CRP (only designed to identify comorbid conditions)

What are some laboratory studies we can do for PAD

Stop smoking, exercise, healthy diet, antiplatelet agents, statins, ACEI/ARB, cilostazol (intermittent claudication), revascularization (endovascular, surgical bypass), amputation (last resort)

Treatment plan for PAD to reduce cardiovascular risk, improve limb-related symptoms, and prevent critical limb ischemia

Giant cell arteritis (GCA)

Chronic vasculitis affecting large and medium sized arteries - commonly branches of the external carotid such as the temporal artery that can lead to vision loss, stroke, aortic aneurysm formation and dissection

ESR, CRP, ALP, U/S (halo sign)

70 y/o female presents to the ER for a severe temporal HA. She also reports pain while chewing, tongue pain, vision loss, stiffness in shoulders, and difficulty swallowing. On a physical exam you node scalp tenderness and nodular temporal arteries. Vitals are stable with the exception of a fever. What labs or imaging do you want?

temporal artery biopsy

What is the gold standard diagnostic for GCA?

Steroids (prednisone, methylprednisolone - taper), low dose ASA, methotrexate/tocilizumab (refractory), prophylactic osteoporosis treatment, monitor for steroid induced effects

Treatment for GCA

ESR, CRP, Watch for HA, visual disturbances, fever; regular glucose and bone health assessments

Game plan for monitoring GCA

Deep vein thrombosis (DVT)

Partial or total thrombotic occlusion of the deep venous system - most often in the legs

endothelial injury, venous stasis, hypercoagulable state

Virchow’s triad - AKA key contributors to DVT

CBC (rule out cellulitis), D Dimer, Compression U/S (1st line), venography (gold standard but invasive), MRI/CT venography

Patient presents to the ER for swelling in her right leg. She recently had a hip replacement and is currently on bed rest. On a physical exam you note warmth, tenderness, and redness in the affected area, pitting edema of the right leg, and a positive Homan’s sign. What fdo you want to order

NOACs (1st line), LMWH, warfarin bridged with heparin; serial imaging

Treatment plan for DVT

LMWH, UFH, DOACs, compression stockings, intermittent pneumatic compression

Primary prevention of DVTs during hospitalizations

long term anticoags in high risk peeps, compression stockings, patient education

Secondary prevention of DVTs

Chronic venous insufficiency (CVI)

Dysfunction in the venous system of lower extremities leading to venous HTN that can be caused by valvular incompetence, DVT, failure of calf muscle pump, varicose veins

distention of veins, capillary leakage, formation of fibrin cuffs

What are the effects of venous HTN in CVI

varicose veins, telangiectases, reticular veins, edema, brown discoloration, eczema, lipodermatoscelerosis, venous ulcer

Clinical manifestations of CVI

duplex U/S

What is the gold standard for diagnosing CVI?

venous photoplethysmography (PPG), air plethysmography (APG)

Additional diagnostic tests for CVI

compression therapy, horse chestnut seed oil, topical steroids (short term), endoscopic perforator vein ligation, venous valvuloplasty, external vein ligation

Treatment plan for CVI

Varicose veins

Dilated, tortuous subcutaneous veins in the superficial venous system of the lower extremities, commonly the greater and long saphenous vein

venous insufficiency, vein wall distention, deep-to-superficial retrograde flow

What causes varicose veins?

family hx, female, pregnancy, standing occupations, sedentary lifestyle, obesity, increased age

Risk factors for varicose veins

worsen with standing, improve with elevation, visible tortuous veins, erythema, hyperpigmentation, scaling ulceration

Quirks of varicose veins

Handheld doppler, duplex U/S (gold standard)

How can we support our clinical diagnosis of varicose veins?

compression stockings, leg elevation, physical activity, sclerotherapy, ligation/stripping of saphenous vein, radiofrequency ablation, endovenous laser ablation

Management of varicose veins

CVI, venous stasis ulcer, increased risk of DVT

Complications of varicose veins

thrombophlebitis

Inflammation of the vein wall along with a thrombosis that often affects superficial veins

trauma/damage to veins, reduced venous flow, increased clotting tendency, buerger’s disease, Behcet’s disease, vasculitis

Risk factors of thrombophlebitis

U/S (proximal veins, during pregnancy)

How do you confirm diagnosis of thrombophlebitis?

Anticoags for 5+ cm (LMWH (pregnant), fondaparinux, rivaroxaban), NSAIDs, compression stockings, leg elevation, early ambulation, refer if recurrent or extensive

Game plan for thrombophlebitis