Vascular Disorders: Arterial Embolism/Thrombosis - AV Malformation

emergency, thrombosis, A fib, superficial, popliteal

Arterial Embolism/Thrombosis: General Info

-Arterial embolism is considered a vascular __________

-Etiologies (many): native arterial ________, arterial injury, arterial embolism, thrombus following intervention, and vasoconstriction/vasospasm. The most common cause, however, is _ ___.

-Most common cause of upper extremity ischemia

-Most common in the ________ femoral or ________ artery in the lower extremities

acute, paresthesia, pulses, capillary, paralysis

Arterial Embolism/Thrombosis Clinical Manifestations:

Symptoms

-____ onset of extremity pain

-Skin color changes

-Neurovascular changes

• ___________

Physical Exam

-Decreased/absent ________

-Decreased __________ refill

-Coolness of the extremity

-Skin mottling

-Decreased sensation

-_________ in severe cases

Paresthesia, pallor, paralysis

6 Ps of Arterial Embolism/Thrombosis

1. ____________

2. Pain

3. ______

4. Poikilothermic

5. Pulselessness

6. _________

clinical, angiography, heparin, IV, reperfusion, vascular

Arterial Embolism/Thrombosis Diagnosis and Management:

Diagnosis

-Usually ________, take a good history and exam

-Bedside arterial doppler

-CT ___________, as long as it won’t impede treatment

Management

-Unfractionated ________ + __ Heparin Infusion

-Pain control

-IV Fluids

-____________ is the mainstay of treatment, consult ________ team

dilation, 3, males, degeneration, aortic, iliac

Abdominal Aortic Aneurysm: General Info

-Focal _______ of abdominal aorta > _ cm

-_______ > females

-Pathophysiology:

• Proteolytic ____________ of _____ wall and connective tissue inflammation

• Aortic bifurcation and common _____ arteries often involved

smoking, white, male, family, HTN, syphilis

Abdominal Aortic Aneurysm Risk Factors

-________

-Age > 60 years

-_____

-______ sex

-________ history of AAA, ___, hyperlipidemia, connective tissue disorders, and ______

infrarenally, white, man

Common Presentation of AAA

-Found __________ and associated with atherosclerotic disease

-Old ______ ___ that smokes is your typical patient

asymptomatic, flank, bruit

Aortic Aneurysm Clinical Manifestations

Symptoms

-Most patients are __________, and their aneurysms are found incidentally

-Some patients may report abdominal, _____, or back pain

Physical Exam

-Abdominal _____

-Pulsatile mass

ultrasound, initial, CT, stable, 5.5

Aortic Aneurysm: Diagnosis

-Abdominal __________ is a great option for hemodynamically unstable patients at bedside

• Great _____ test

-__ scan with IV contrast is the best test in symptomatic, hemodynamically _____ patients

• Indicated when diameter reaches ~ _._ cm

65-75, 100, 10, annual, 6, refer, immediate

Aortic Aneurysm Screening / Management

-Screening Indication: men __-__ years with exposure to ___+ lifetime cigarettes

-Management

• > 2-2.9 cm diameter = repeat imaging in __ years

• 3-4 cm = monitor with _______ ultrasound

• 4-4.5 cm = monitor with ultrasound every _ months

• > 4.5 cm = _____ to vascular surgeon

• > 5.5 cm or > 0.5 cm expansion in 6 months = _________ surgical repair

5.5, pain, open

Aortic Aneurysm Management

-Elective repair

• Indicated with aneurysms > _._ cm, growing aneurysms, or patients with aneurysm + _____

-Surgical options

• _____ surgery or endovascular

atherosclerosis, asymptomatic, cough, edema, widened

Thoracic Aortic Aneurysm: General Info

-Primary etiology = _____________

-Most are ____________, but some patients do present with varying symptoms

• neck/back pain, dyspnea, dysphagia, hoarseness, or brassy _______

-Physical exam = stridor, ______ in neck/arms, distended neck veins

-Findings = ________ mediastinum on CXR

CT, contrast, cardiac, vascular

Thoracic Aortic Aneurysm: Diagnosis and Referral

-Diagnosis = __ scan with IV _______ is the test of choice

-Referral:

• Ascending aorta → _______ surgeon

• Descending aorta → _________ specialist

tear, lateral, hemorrhage, lumen, ascending, descending

Aortic Aneurysm Dissection: General Info

-Circumferential or transverse ____ of the intima of aorta

-Often occurs along right _______ wall

-Initiating event could be primary intimal tear or medial ___________, both of which create a false _____ for blood to go into

-Stanford Type A = __________ aorta affected

-Stanford Type B = ___________ or transverse aorta affected

sudden, pain, back, hypotension, edema, neurologic

Aortic Aneurysm Dissection Clinical Manifestations

Symptoms

-_______ onset of chest pain, described as severe/tearing. Can radiate to the ______ or shoulder blades

-Usually associated with diaphoresis

-± syncope, dyspnea, weakness

Physical Exam

-Hyper/___________

-Loss of pulses

-Aortic regurgitation murmur

-Pulmonary ____

-________ findings: paraplegia, hemiplegia, hemianesthesia

D-Dimer, 500, LFT, mediastinum, left, normal, angiography

Aortic Aneurysm Dissection Diagnosis

-Elevated lab values = _-____ ( < ___ is unlikely to be a dissection), cardiac enzymes, ___, and lactate

-CXR = widened _________, ± ____-sided pleural effusion, or completely normal

-EKG = usually _______, helps you rule out MI

-CT __________ is the test of choice to rule out dissection, MI, and PE

admit, beta-blockers, 60-80, high, medical, surgical

Aortic Aneurysm Dissection Management

-_______ the patient, and immediately consult vascular or cardiothoracic surgery

-_____-________ like IV propranolol or metoprolol. Goal HR is __-__ BPM. Give with pain medicine.

-Nitroprusside if the BP is still _____ after managing HR and pain

-Uncomplicated Stanford Type B = ______ therapy

-Complicated Stanford Type B or Type A = _______ correction

nonatherosclerotic, thrombotic, males, 20-45, smoking

Thromboangiitis Obliterans: General Info

-____________, segmental, inflammatory, and ________ disease that affects small-medium size vessels of the upper and lower extremities

-_____ > females, most commonly in __-__ year old

-Risk Factors = ________ (rolling your own cigarettes) and severe periodontal disease

smoking, without, fibrosis, plantar

Thromboangiitis Obliterans Pathophysiology

-Pathophysiology is poorly understood, but _________ is an essential risk factor for each disease stage

-Acute = inflammatory thrombus development ________ necrosis

-Intermediate = progressive organization of thrombus in small-medium vessels

-Chronic = inflammation resolves, organized thrombus and ______ remains

-_______ and digital vessels are the most common

pain, ulcerations, superficial, ischemia, Raynaud’s, 3

Thromboangiitis Obliterans Clinical Manifestations

Symptoms

-Rest _____ of the distal most extremity (toes), early manifestation

-_________/arthralgia in late disease

Physical Exam

-________ thrombophlebitis

-Distal extremity ________ to upper and lower extremities

-_______’_ phenomenon

-Check all extremities, for this is often present in _+ limbs

clinical, biopsy, corkscrew

Thromboangiitis Obliterans Diagnosis

-Typically ______ diagnosis using clinical criteria

-Labs obtained to rule out other disease process like scleroderma

-______: shows segmental vascular inflammation, confirms diagnosis

-Aortography: shows ________ collaterals

50, tobacco, exclusion

Clinical Criteria for the Diagnosis of Thromboangiitis Obliterans:

1. Age < __ years

2. Current or recent history of ________ use

3. Distal extremity ischemia

4. Typical arteriographic findings of TAO

5. ________ of autoimmune disease, thrombophilia, diabetes, and proximal embolic sources

smoking cessation

Thromboangiitis Obliterans Management

-_______ _________ is the cornerstone of management, nothing is as effective in stopping disease progression

-Wound care

-IPC

-Iloprost

-CCBs (Nifedipine)

panarteritis, 70-80, women, age, menopause

Giant Cell Arteritis: General Info

-Systemic __________ (inflammation) affecting medium and large size vessels

-Frequently coexists with polymyalgia rheumatica

-Peak incidence in patients __-__ years old

-_______ > men

-Risk Factors: increased ___, genetic predisposition, history of smoking, early ________, and lower BMI

headache, jaw, visual, scalp, pulses, fundoscopic

Giant Cell Arteritis Clinical Manifestations

Symptoms

-___________ is the most common, classic symptom

• Be concerned about new onset headache and localized pain

-___ claudication with mastication, _______ changes, _____ tenderness, fever, fatigue, weight loss, night sweats, malaise

Physical Exam

-Temporal artery abnormalities, decreased peripheral _______

-Aortic regurgitation murmur

-Supraclavicular/axillary bruits

-Abnormal ________ exam

ESR, CRP, alk phos, biopsy, giant, halo

Giant Cell Arteritis Diagnosis

Labs

-Elevated ___, ___, and ___ ____

-CBC shows normochromic normocytic anemia

Definitive Diagnosis

-Temporal artery ______ is the gold standard

• Transmural inflammatory infiltrate comprised of lymphocytes, macrophages, ± _____ cells

-Temporal artery CDUS

• + _____ sign of temporal arteries, which can also be diagnostic

corticosteroids, predisone, methylprednisone, methotrexate

Giant Cell Arteritis Management

-Initiate therapy ASAP

-First line therapy = high dose ____________

• No symptoms of ischemic organ damage = ________

• Signs/Symptoms of ischemic organ damage = ___________ for 3 days and then prednisone taper

-Additional therapy = tocilizumab or ____________

narrowing, lumen, stroke, atherosclerosis, asymptomatic

Carotid Artery Stenosis: General Info

-________ of carotid artery ____, may be symptomatic or asymptomatic

-TIA/_____ is the worst consequence of this

-Most cases due to ___________

-Prevalence of __________ disease is low

age, male, stroke, angiography, carotid

Carotid Artery Stenosis Classification and Risk Factors

Classification

-Symptom status

-Degree of stenosis, most pts are 60%

Risk Factors

-Advanced ___, ____ sex, family history, CAD, PAD, smoking, diet, obesity, DM, HTN

-Major risk factor for ischemic _____

Imaging Modalities

-Duplex US, MR angiography, contrast enhanced MRA, CTA

-Cerebral __________ is the gold standard for imaging _______ arteries

cessation, statin, CEA, elderly, asymptomatic, 70

Carotid Artery Stenosis Management/Screening

Management

-Medical Therapy

• Smoking _________

• BP control; < 140/90 mmHg

• ______ therapy

• Antiplatelet therapy

-Invasive Therapy

• Carotid endarterectomy (___), preferred in most patients

• Stenting has better results in the elderly

-Routine Screening

• Not recommended in ___________ patients

-When to Refer

• Patients with > __% stenosis

• Symptomatic patients (immediately)

malformation, increase, head

Arteriovenous Malformation: General Info

-Type of vascular ________

-Rare, associated with ________ morbidity and mortality

-Can affect any organ, but the _____ and neck are the most common sites

birth, proportionately, predictable, 2nd-3rd, stroke

Arteriovenous Malformation

-Developmental vascular malformation, present at ______

-Grow ___________ with the individual

-________ growth pattern, with tendency to progress in the ___-___ decades of life

-Thought to expand in response to certain stimuli

-Complications = hemorrhagic ____, intraparenchymal hemorrhage, epilepsy, headache, and neurological defects

telangiectasia, mass, thrill, bruit

Arteriovenous Malformation Clinical Manifestations

Physical Exam

-___________ / macular stains

-Faint, red-purple, ill-defined cutaneous ____

-Slightly compressible

-+ palpable pulsations or _____

-+ audible ____

-Stages I - IV, based on progression

ultrasound, classifies, failure

Arteriovenous Malformation Diagnosis

-________ (US): identifies AV malformation and useful for follow-up

-Catheter-based angiography: _________ AV malformation

-ECHO: recommended for evaluation of heart _______ or right heart strain

early, pain, compression, resection, palliative

Arteriovenous Malformation Management

-______ diagnosis is critical for improving the patient’s quality of life

-Multidisciplinary team-based approach

-Asymptomatic/isolated AV malformations = conservative therapy

• ____ management

• Physical therapy

• __________ therapy

-Symptomatic Lesions = vascular intervention/surgery

• Embolization, surgical _________, sclerotherapy

• _________/goal oriented care may be the only option for complex/diffuse disease