Arterial Vascular Disease - Clin Med

What does this refer to

• A 65-year-old woman presents to the emergency department due to a severe headache and visual impairment in the right eye.

• Her symptoms are associated with pain with chewing and proximal muscle morning stiffness.

• On physical exam, she has decreased visual acuity of the right eye, scalp tenderness on the right, and an absent pulse in the right temporal area.

• Laboratory testing is significant for an elevated erythrocyte sedimentation rate.

• She is admitted and immediately started on systemic glucocorticoids.

Giant cell arteritis

What does this refer to

Giant cell arteritis

What does this refer to

• Chronic vasculitis of large and medium sized vessels

• Vascular involvement may be widespread

• Most frequently involves cranial branches of arteries that originate from aortic arch

• Also known as temporal arteritis

Giant Cell (Temporal) Arteritis

What does this refer to

• Age greater than 50 years (peaks at 60-80)

• Risk for blindness

  • More common in whites; rare in Hispanics

• More common in Scandinavian descen

• Clustering of illness may occur in families

• Heavy smoking increases risk in women

• F > M

EpidemiologyGiant Cell (Temporal) Arteritis

What does this refer to

• Unknown/idiopathic —> presumed to be autoimmune

• T-cells and monocytes “recruited” to vessel wall = inflammatory response

• Association with polymyalgia rheumatica (also autoimmune)

• Infectious etiology has also been speculated

Etiology Giant Cell (Temporal) Arteritis

What does this refer to

Clinical history Giant Cell (Temporal) Arteritis

What does this refer to

• Palpate Pulses

  • Carotid

  • Brachial

  • Radial

  • Femoral

  • Pedal

• Temporal artery abnormalities

  • Tender or thickened

  • Absent temporal pulse

Physical Exam of Giant Cell (Temporal) Arteritis

What does this refer to

Giant Cell (Temporal) Arteritis - (Visibly enlarged temporal artery)

What does this refer to

• Headache

• Scalp tenderness

• Thickened temporal arteries

• Jaw claudication

• Acute visual loss

• Weight loss, anorexia, fever, night sweats

• Malaise, depression

Presenting symptoms of Giant Cell Arteritis

What does this refer to

• Considered in age > 50 years old who has:

  • New headaches

  • Abrupt onset of visual disturbances

  • Symptoms of polymyalgia rheumatica

  • Jaw claudication

  • Unexplained fever or anemia

  • High ESR and/or high serum CRP

Diagnosis Giant cell (temporal) arteritis

What does this refer to

• Migraine headache

• Takayasu arteritis

• Polymyalgia rheumatica (may co-occur with GCA)

• Trigeminal neuralgia

• Atherosclerotic Disease of Carotid Artery

Differential diagnosisGiant Cell (Temporal) Arteritis

What does this refer to

Workup for giant cell arthritis

What is the diagnostic test for giant cell arthritis

temporal artery biopsy

What does this refer to

• Age (50 at time of onset)

• Localized headache of new onset

• Tenderness or decreased pulse of temporal artery

• ESR > 50 mm/hour

• Biopsy (revealing necrotizing arteritis with mononuclear cells or multinucleated giant cells)

Classification criteriaGiant Cell (Temporal) Arteritis

What does this refer to

• Rheumatologist

• Ophthalmologist

• Vascular surgeon

• Neurologist

Clinical intervention (Referrals/Consults)Giant Cell (Temporal) Arteritis

What does this refer to

• High dose glucocorticoids

  • Prednisone

  • Optimal dose for initial treatment uncertain

  • *Initial daily dose of Prednisone 40-60 mg of prednisone

• Acetylsalicylic Acid (ASA)

Clinical managementGiant Cell (Temporal) Arteritis

What does this refer to

• Symptoms usually controlled promptly and tapering can begin once disease has been controlled adequately

• After 2-4 weeks of high dose Prednisone

  • Is Patient asx and the ESR normal? YES  taper

    • Begin tapering 2.5-5mg/day every 2 weeks to a dose of 20mg/day

      • Then decrease dose by 10% every 2 weeks to a dose of 10mg/day

        • Then decrease dose by 1mg/day every 4 weeks

• Flares are the rule if tapered too quickly

Glucocorticoid taperingGiant Cell (Temporal) Arteritis

What does this refer to

• SE of high dose/long term steroid use is decreased bone density

• Prevent this decreased bone density with prophylactic tx

• Prophylactic measures

  • Obtain a baseline bone density (when patient starts steroids)

  • Administer (1500 mg of calcium/800 IU of vitamin D-3 per day)

  • Consider bisphosphonates or hormonal therapy for osteopenia/osteoporosis

Prophylaxis of decreased bone densityGiant Cell (Temporal) Arteritis

What does this refer to

• Many patients tend to run a self-limited course over several months to several years

• Dose can eventually be reduced and discontinued in the majority of patients

• A few may need low dose prednisone for years

• Complications

  • Blindness

  • 20-50% have recurrence

  • Some patients have GCA and PMR at the same time

Prognosis/patient educationGiant Cell (Temporal) Arteritis

What does this refer to

• A 67-year-old man presents to his primary care physician due to vague epigastric discomfort.

• He denies it being associated with meals and reports that this pain occurred insidiously.

• Medical history is significant for hypertension.

• He has been smoking 1-pack of cigarettes per day for the past 30 years.

• On physical exam, he has a pulsatile abdominal mass that is tender to palpation.

• An abdominal ultrasound is performed, which demonstrates a 6 cm abdominal aortic aneurysm.

• He is scheduled for an elective abdominal repair surgery for the following day.

Aortic aneurysm and dissection

What does this refer to

• Aneurysm: arterial dilation

  • Diameter of that region is increased > 50% relative to normal aortic diameter

  • Normal diameter of the aorta at the level of the renal arteries is approximately 2.0 cm (range 1.4 to 3.0 cm) in most individuals

  • Diameter greater than 3.0 cm is generally considered aneurysmal

Aortic Aneurysm

What does this refer to

• Abdominal (aortic aneurysm) (AAA)

• Thoracic

  • Ascending (aorta)

  • Aortic arch

  • Descending (aorta)

Most Common types of Aortic Aneurysms

What does this refer to

Re

What aneurysm shape is the following

• bulging on one side

Saccular

What aneurysm shape is the following

• Bulging on all sides

Fusiform

What aneurysm shape is the following

• hematoma that forms as the result of a leaking hole in an artery

Pseudoaneurysm

What does this refer to

• Weakening of the aortic wall

  • breakdown of the extracellular matrix proteins elastin and collagen (help vessels hold their structure/shape)

• Congenital- anatomic defect

• Atherosclerosis

• HTN

• DM

• Smoking

Etiology/Pathogenesis/Risk Factors Aortic Aneurysm

What does this refer to

• Marfan’s syndrome

Risk factor of aortic aneurysm

What does this refer to

• Occasionally may cause discomfort

• More concern is risk of rupture

  • severe pain

  • massive internal hemorrhage

  • without prompt treatment, death occurs rapidly

Clinical historyAortic Aneurysm

What does this refer to

• Communication through a “stalk” from the artery to the “sack”

• Hematoma often develops within the sack

Pseudoaneurysm

What does this refer to

• Often asx until dissection begins

• Abdominal/chest pain and back pain

  • “Gnawing, ripping or tearing” abdominal pain

• Compression of nerve roots

• Associated sx:

  • Anxiety

  • N/V

  • Clammy skin

  • Tachycardia

Clinical history of aortic aneurysm

What does this refer to

• May be incidental on rad scans

• Palpable, pulsatile abdominal mass

• Groin pain

• Skeletal hip pain

Other symptoms/findings of aortic aneurysm

What does this refer to

• May be palpable as a pulsatile mass (AAA)

• Bruit may be heard from turbulent blood flow (AAA)

  • “Gushing noise”

• BP May be elevated followed by a sudden Hypotensive episode

• Persons w/ Marfan syndrome are often males that are tall and “skinny”

  • Long extremities, fingers

Pertinent physical exam findings of Aortic Aneurysm

What does this refer to

• Abdominal pain

• Hypotension

• Pulsatile abdominal mass

Ruptured or leaking AAA “triad” Aortic Aneurysm

What does this refer to

Pulsatile massAortic Aneurysm

What does this refer to

Pertinent historical findings/clinical sx (Thoracic) aortic aneurysm

What does this refer to

• Angina Pectoris

• Myocardial infarction

• Pulmonary embolism

• Pancreatitis

• Gastroenteritis

• Mechanical back pain

Differential DiagnosisAortic Aneurysm

What test is gold standard and confirmatory of aortic aneurysm

Angiography

What does this refer to

Workup aortic aneursym

What does this ultrasound refer to

aortic aneurysm

What does this chest x-ray refer to

Thoracic Aneurysm

What does this CT refer to

Thoracic Aneurysm

What does this CT refer to

Abdominal Aortic Aneurysm

What does this angiogram refer to

Aortic Aneurysm

What does this CT angiography refer to

Aortic aneurysm

What does this refer to

• Strict BP control

• Smoking cessation

• Refer to a vascular surgeon

  • Decide if surgical candidate

  • Recommendations about how to follow the patient clinically

    • Example might be ordering CT q 6 mo to monitor growth

Medical management of aortic aneurysm

What does this refer to

• Prevent RUPTURE!

• Aneurysms >5.5 cm (5 cm in good operative candidates) often surgically repaired

• Symptomatic PTs with any size aneurysm often candidates for surgery

• U/S every 6 months for aneurysm 4-4.5cm

• U/S annually for aneurysms 3-4 cm

• Thoracic aneurysm surgery more complex with greater risks

• Surgery may be delayed until absolutely necessary

Surgical ManagementAortic Aneurysm

What does this refer to

• Open surgical repair vs. endovascular

  • Open repair

    • Low or average risk of operative complications

    • Direct visualization

  • Endovascular repair

    • High risk of complications from open operations

    • Minimally invasive

    • Access usually through femoral arteries

Surgical candidates aortic aneurysm

What does this refer to

Open RepairAortic Aneurysm

What does this refer to

Endovascular repair aortic aneursym

What does this refer to

• 1-time screening with ultrasonography

  • Men aged 65 to 75 yo

  • Men aged 65 to 75 years who have ever smoked

Screening/Health MaintenanceAortic Aneurysm

What does this refer to

Aortic dissection

What does this refer to

• Tear in the inner wall of the aorta (intima) causes blood to flow into the middle layer (media) and force the layers apart

Aortic dissection

What does this refer to

Etiology/Pathogenesis/Risk Factors Aortic Dissection

What does this refer to (in terms of aortic dissection)

• Most simplified classification system EVER!

• Stanford system divided into:

  • Stanford Type A (proximal)

    • _______________

Involves the Ascending aorta

What does this refer to (in terms of aortic dissection)

• Most simplified classification system EVER!

• Stanford system divided into:

  • Stanford Type B (distal)

    • __________

Does NOT involve the ascending aorta

What does this refer to

Stanford Typing SystemAortic Dissection

What does this refer to

• Most commonly in the aortic arch or L subclavian

• Always include in differential of chest pain

• Typically c/o severe sharp, “tearing” (ripping) sensation in the chest or back

  • Be suspicious of dissection in high risk patients c/o pain radiating to the back

• Pain may migrate as the dissection extends

• Stanford Type A-chest pain anteriorly—may hear new murmur in aortic area

• Stanford Type B-may see pain between scapular areas/back pain.

• Neck or jaw pain may occur with involvement of aortic arch

Pertinent Historical findings/clinical SxAortic Dissection

What does this refer to

• Peripheral extremity pulses may be decreased

• Elevated BP in most cases (may see decreased BP)

• Difference in pulse amplitude (strength)

• Unequal BP in upper extremities (UE)

• Aortic valve or ascending is affected  new aortic regurgitation murmur

Pertinent Physical Exam Findings Aortic Dissection

What does this refer to

• Aortic embolism

• Acute MI

• Angina Pectoris

• Pulmonary embolism

• Pancreatitis

• Gastroenteritis

• Mechanical back pain

Differential Diagnosis Aortic Dissection

What does this refer to

• Widened mediastinum on CXR

• Transesophageal echocardiography (TEE) esp if AKI or contrast allergy

• CT scan Chest, Abd, Pelvis with IV Contrast when TEE cannot be quickly performed

• Sonography SPEED protocol

• Aortic angiography (MRI) is gold standard

  • Not universally available

  • Expensive

Workup aortic dissection

What does this refer to

• SPEED

  • Sonographic Protocol for the Emergent Evaluation of (Aortic) Dissections

  • Combines TTE and abdominal aorta US

    • Abdominal aorta 6”

    • Xiphoid to bifurcation (iliacs)

• Designed for patients too unstable to leave the ER for imaging

Workup – Speed ProtocolAortic Dissection

What does this refer to

Transesophageal echoAortic Dissection

What does this CT scan with IV contrast refer to

Aortic Dissection

What does this CT chest refer to

Aortic Dissection

What does this coronal CT view refer to

Aortic Dissection

What does this angiography refer to

Aortic Dissection

What does this refer to

• Acute dissection suspected

  • Labetalol and sodium nitroprusside IV typically used to aggressively lower BP

  • Lowest level that adequately supports cerebral, cardiac and renal perfusion

    • Goal is systolic BP 100-120mmHg within 20 mins

• Hypotensive

  • IVF and vasopressors

    • Dopamine/Dobutamine

    • Epinephrine/Norepinephrine

• Patients with a dissection that does not threaten organs may be observed with strict BP control

  • MUST be completely asymptomatic

  • At discretion of CT specialist

    • Cardiologist specializing in vascular repair

  • Beta blocker often used as first line

Medical Management Aortic Dissection

What does this refer to

• Tx choice often depends on location

  • Stanford type A (ascending aortic) dissection

    • Immediate Open surgical mgmt superior to medical mgmt

  • Uncomplicated Stanford type B (distal aortic)

    • Medical mgmt preferred over surgical intervention

    • Repair if evidence of rupture or vessel occlusion

Medical management of aortic dissection

What does this refer to

• Objective is often to resect (remove) the most severely damaged segments of the aorta, and prevent entry of blood into the false lumen

  • Graft inserted post resection

Surgical ManagementAortic Dissection

What does this refer to

peripheral arterial disease

What does this refer to

• A 50-year-old man presents to his primary care physician for pain in his lower legs with long walks.

• He reports walking 10 blocks before feeling the pain and that it resolves with rest.

• His medical history includes hyperlipidemia, hypertension, and diabetes.

• His blood pressure is 145/80 mmHg, pulse is 90/min, and respirations are 18/min.

• On physical exam, his distal pulses are faint.

• His bilateral calves are dry and hairless with no peripheral ulcers.

• His skin is cool to the touch, especially in his feet.

• An ankle-brachial index is performed.

Peripheral vascular disease

What does this refer to

• Atherosclerotic disease leading to peripheral artery obstruction

• PAD regarded as a coronary heart disease risk equivalent

Peripheral Artery Disease (PAD)

What does this refer to

• Age ≥70 years

• Age 50-69 years with a history of smoking or diabetes

• Age 40-49 with diabetes and at least one other risk factor for atherosclerosis

• Known atherosclerosis at other sites (coronary, carotid, or renal artery disease)

• Positive Family history

• Smoking

• HTN

• HLD

• M > F

• AA > Caucasian

EpidemiologyPeripheral Artery Disease (PAD)

What does this refer to

• Risk factors

  • Similar to those for development of coronary atherosclerosis

• Most often affects the popliteal artery

• Atherosclerotic disease —> obstruction of peripheral arteries

• Associated Conditions

  • Leriche syndrome —> aortoiliac occlusion

    • BLE claudication

    • PLUS impotence

    • PLUS lower extremity muscular atrophy

• CAD

Etiology of peripheral artery disease (PAD)

What does this refer to

• Progressive severity

  • asymptomatic

  • intermittent claudication

  • pain at rest

  • nonhealing wounds

  • ulceration

  • gangrene and threatened limb

Clinical history of Peripheral Artery Disease (PAD)

What does this refer to

Physical exam peripheral artery disease (PAD)

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