Cardio E2: Vasculature diseases

What is the most common cause of peripheral artery disease?

Atherosclerosis

What does PAD correlate to?

Cardiovascular mortality

What are some traditional risk factors for PAD?

Tobacco, DM, Age

What are some non-traditional risk factors for PAD?

CKD, Hypercoagulable states

What key sign differentiates venous vs. arterial disease?

PULSES- if arterial, pulses are diminished or absent

Ischemia of which vessel would cause claudication in the buttocks/hip?

Aortoiliac

Ischemia of which vessel would cause claudication in the thigh?

Common femoral or aortoiliac artery

Ischemia of which vessel would cause claudication in the upper calf?

Superficial femoral artery

Ischemia of which vessel would cause claudication in the lower calf?

Popliteal artery

Ischemia of which vessel would cause claudication in the foot?

Tibial or peroneal artery

If ischemia is located in the aortoiliac artery, what site will likely have claudication?

Buttock/hip or thigh

If ischemia is located in the common femoral artery, what site will likely have claudication?

Thigh

If ischemia is located in the superficial femoral artery, what site will likely have claudication?

Upper calf

If ischemia is located in the popliteal artery, what site will likely have claudication?

Lower calf

If ischemia is located in the tibial or peroneal artery, what site will likely have claudication?

Foot

What does an ABI greater than 1.4 suggest?

Calcification/hardening of vessel- refer to specialist

What is a normal ABI range?

1.0-1.4

What does an ABI less than 0.5 suggest?

Severe arterial disease- refer to specialist

What fluoroscopic technique is used extensively in IR for visualizing blood vessels?

Digital subtraction angiography (DSA)

What is the gold standard for diagnosis of PAD?

Angiography

What is the first line management for PAD?

Supervised exercise program

In management of PAD, what does a supervised exercise program increase?

Collateral circulation

For continued symptoms of PAD despite initial therapy, which medication should be given?

Cilostazol (PDE3 inhibitor)

What other medications may be used in the management of PAD?

Aspirin, Clopidogrel (Plavix), Statins

What are the 6 P's of acute ischemia?

Pain, Pallor, Pulselessness, Paresthesias, Poikilothermia, Paralysis

What is Arteriosclerotic obliterans?

Atheromatous disease of the coronaries but peripheral

What does Arteriosclerotic obliterans cause?

"Angina" of the ischemic limb

What is Leriche syndrome?

Claudication of the buttocks meaning narrowing higher up in the terminal aorta

What is Arteriosclerotic obliterans?

Termed "intermittent claudication" that occurs predictably with activity and is relieved with 1-2 mins of rest

What diseases causes a post-exercise fall of BP in the compromised limb?

Arteriosclerotic obliterans

What is "Buerger's Disease"?

Thromboangiitis obliterans

Which diseases have a triphasic color scheme (white, blue, red)?

Thromboangiitis obliterans, Raynaud's, Chronic arterial insufficiency

Thromboangiitis obliterans is commonly seen in young people and related to what?

Tobacco use

What is an AV fistula?

Arterial flow enters venous, high output state, bounding pulses, with a "thrill" over discrete fistula

What are some causes of acquired AV fistulas?

Penetrating trauma, Malignancy, Infection

What is a cause of congenital AV fistulas?

Cavernous hemangioma

What are the 3 arterial vasospastic disorders?

Raynaud's, Livedo reticularis, Acrocyanosis

Which patient population is Raynaud's commonly seen in?

Young females

What is the treatment for Raynaud's?

CCBs

What disease has a "Fishnet" pattern?

Livedo reticularis

What is the most common disorder of the venous system?

Venous insufficiency (reflux)

Venous insufficiency is generally the result of _______________ of venous vessels in the leg

Over-dilation

Varicose veins (are/are not) caused by crossing the ankles/legs

ARE NOT

Varicose veins are most common in the ______________ veins of the legs

Superficial

When are symptoms of varicose veins exacerbated?

At night and after exercise

Which stage of vein disease:
Spider veins

Stage 1

Which stage of vein disease:
Varicose veins

Stage 2

Which stage of vein disease:
Leg edema

Stage 3

Which stage of vein disease:
Skin changes

Stage 4

Which stage of vein disease:
Leg ulcers

Stage 5

What do Venous ulcers occur secondary to?

improper valvular malfunction

In chronic arterial insufficiency, where do ulcers most commonly occur?

Dorsum of foot (or lateral malleolus)

What is a sign of chronic arterial insufficiency?

"Punched out" painful ulcers on the dorsum of the foot

Arterial or Venous disease:
Lesions on medial lower leg/ankle

Venous

Arterial or Venous disease:
Lesions on toes, dorsum of foot, lateral ankle

Arterial

Arterial or Venous disease:
Ulcer appears with little drainage & little tissue granulation

Arterial

Arterial or Venous disease:
Ulcer appears pale/light pink or necrotic/black

Arterial

Arterial or Venous disease:
Ulcers are "punched-out"

Arterial

Arterial or Venous disease:
Ulcers are swollen with drainage and granulation is present

Venous

Arterial or Venous disease:
Ulcer appears deep pink/red

Venous

Arterial or Venous disease:
Ulcer has irregular edges and is shallow

Venous

Are AAAs or TAAs more common?

AAAs

Are males or females more likely to have an aortic aneurysm?

Males

What are some risk factors for aortic aneurysms?

CAD & HTN, Older males, Tobacco use, Hypercholesterolemia

What is a sign of most intact aortic aneurysms?

Asymptomatic

What is a common sign seen in patients presenting with aneurysm of the arch of the aorta?

Hoarse voice (stretching of L recurrent laryngeal nerve)

What is Cardarelli's sign?

An abnormal pulsation of the trachea that may be found in patients with an aneurysm of the aortic artch

Cardarelli's sign is seen what type of aneurysm?

Aortic arch

How can Cardarelli's sign be felt?

By displacing the thyroid cartilage to patient's left

What type of aortic aneurysms are usually found incidentally on imaging, and patients are often asymptomatic?

Thoracic

What are some symptoms that may occur as a TAA grows?

CP, Tearing, Severe back pain, Hoarseness, Cough, SOB

What CXR findings are associated w/ a TAA?

Widening of mediastinum, enlargement of aortic knob, or displacement of trachea from midline

What is the gold standard for diagnosis of a TAA?

CTA

Which layers of the vessel are involved in most AAAs?

All 3

The risk of rupture of an AAA is related to what?

its diameter

When the AAA reaches about _____ cm for males, the patient definetly needs surgery!

5.5

Are fusiform or saccular aneurysms less prone to rupture?

Fusiform

What are the classic symptoms associated with a ruptured AAA?

Severe, constant abdominal pain that radiates to the back

AAAs often present as a large, pulsatile mass above what?

the umbillicus

Which patient population should be screened for AAA via ultrasound annually?

All male smokers over 65 y/o

What is the best test to diagnose an AAA and guide treatment?

CTA

What may be heard upon auscultation of an AAA?

Bruit

The risk of aneurysm enlargement may be diminished with what interventions?

BP control, Smoking cessation, Minimizing cholesterol levels

Which type of aneurysm (AAA or TAA) has a higher surgical mortality?

TAA

A patient with an ascending TAA should have surgery when the size is ________

5-6 cm

A Marfan's patient with an ascending TAA should have surgery when the size is ________

5 cm

A patient with a descending TAA should have surgery when the size is ________

6-7 cm

A male patient with an AAA should have surgery when the size is ~ ________

5.5 cm

A female patient with an AAA should have surgery when the size is ________

5 cm

Where does aortic dissection most commonly occur?

Ascending thoracic aorta

What is a sign of Aortic dissection?

Characteristic chest or abdominal pain described as "tearing sensation"

In aortic dissection, what is created when blood travels through the media?

False lumen

What is the initiating event in an aortic dissection?

Tear in the intimal lining of the aorta

DeBakey or Standford classification:
Categorizes dissection based on where the orignial intimal tear is located and the extent of the dissection

DeBakey

DeBakey or Standford classification:
Divided into two groups depending on whether the ascending aorta is involved

Standford

What is the most common cause of death from aortic dissection?

Pericardial tamponade

What is the gold standard for diagnosis of an aortic dissection?

CTA

What is the first line treatment for aortic dissection?

IV Beta Blockers