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102 Cards in this Set
- Front
- Back
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what is the most common etiology for peripheral vascular disease?
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Atherosclerosis
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what area of the body is most affected by peripheral vascular disease?
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lower extremities- calf areas
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what is the primary symptom of peripheral vascular disease? what makes it better and worse?
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Claudication: Aching, cramping, fatigue, weakness in the calves, thighs or buttocks brought on by walking and completely relieved after a few minutes of rest. Relieved with rest. Worse with exertion. Predictable.
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what will you see of PVD on PE?
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smooth, shiny, hairless skin on lower extremities.
Diminished or delayed distal pulses. Severe ischemia causes pallor, cyanosis, decreased skin temperature, ulceration and may cause gangrene |
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how do you usually make the diagnosis of PAD?
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the signs and symptoms
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what is the ankle-brachial index? what's normal? what is PVD's index?
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In normal patients, the systolic blood pressure in the leg is slightly higher than in the arm (ankle-brachial index > 1.0). In PVD, the index decreases. <.9=PVD
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what is the function of ultrasounding for PAD?
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to quantify the extent of dz. May also help dx those pts with noncompressible vessels
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what happens to the ankle-brachial index as the disease progresses?
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the index with decrease
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what are the three phases of treatment of PAD?
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1) conservative, 2) medical, 3) surgical
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what are the tx options of conservative therapy?
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lifetyle changes- regular walking may increase distance prior to claudication up to 400%. STOP SMOKING.
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what are the medical txs that we can use for PAD?
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pentoxifylline, cilostazol, lipid lowering agents, HTN agents, aspirin, clopidogrel
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which medical tx looks the most favorable?
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cilostazol
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what are the indications for surgery?
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-severe claudication that is resistant to medical therapy
-limb threatening ischemia -vasculogenic impotence |
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what is acute limb ischemia?
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VASCULAR EMERGENCY!
Sudden occlusion of a peripheral artery is caused by either arterial embolism or thrombosis in situ. |
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what are the two major places that we get thrombi from?
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deep veins and left atria (during a-fib)
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what are the symptoms of limb ischemia from an arterial embolism?
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Sudden onset of symptoms without history of claudication. Pain!
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DVT vs Acute Limb Ischemia, how can you tell the difference?
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DVT- warm foot or swelling because you are not getting a good outflow of blood.
ALI- cold, cyanotic and not swelling |
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on physical exam, what does acute limb ischemia look like?
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Cold, cyanotic (bluish) extremity
Absent pulses distal to the occlusion |
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what two techniques can you use to diagnose acute limb ischemia? what can each one of these techniques determine?
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hand-held doppler- assess flows at different arterial segments
transesophageal echocardiography (TEE)- to determine the potential cardiac source. |
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what is the tx for acute limb ischemia?
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anti-coag (IV heparin)
embolectomy catheter-directed infusion of plasminogen activator (tPA), a fibrinolytic emergent amputation if tissue necrosis |
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how big is a normal aorta? when is it concerned an aneurysm? when does the size of the aorta start to become worrisome and requires intervention?
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2 cm; 3cm; >5 cm
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what is the major concerns of AAA's?
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rupture which is an immediate life-threatening condition
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In what type of population are AAA's more common?
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older adults
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what are the causes of AAA's? what is the main one?
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Atherosclerosis*, Cystic Medial Necrosis (Marfans, Ehlers-Danlos), vasculitis with connective tissue disease (Takayasu’s arteritis, giant-cell arteritis), chronic infection (syphilitic aortitis), and trauma.
main- atherosclerosis |
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when the risk of a rupture start to increase?
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when diameter >5 cm
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what are the symptoms and Signs of AAA?
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nontender pulsatile mass BELOW umbilicus if <5 cm.
Hypotension, acute abdominal/ back pain |
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what should prompt consideration of aneurysm rupture?
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elderly pt with hypotension, acute abdominal/ back pain.
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how do you diagnose AAA?
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duplex ultrasonography
CT, MRA allow visualization of the thoracic and abdominal aorta and iliac arteries and its branches |
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how do you tx an AAA (if they are inbtwn 3 and 5 cm)?
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stop smoking
conrtol BP lower cholesterol come in for an exam every 6-12 months |
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how do you tx an expanding AAA? (ie 6 months ago it was 3 cm and now its 4)
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surgical repair.
Open surgical repair or percutaneous endovascular graft placement. |
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where does the aortic dissection typically occur?
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in thoracic aorta
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what are the risk factors for aortic dissection?
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HTN, cocaine use, trauma (like a car accident), herditary CT disease, vasculitis
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what are the two types of aortic dissections based on the stanford system?
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type a- involves the ascending aorta
type b- involves the distal aorta |
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what are the three types of aortic dissection based on the debakey system?
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type 1- entire aorta
type 2- only ascending aorta type 3- only descending aorta |
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what is the key symptom of aortic dissection?
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ripping or tearing pain
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what can retrograde propragation of the Aortic dissection cause?
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pericardial tamponade or CADissection w/ acute MI
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how would you diagnose an Aortic dissection?
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CT angiography and TEE (slow)
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which type of aortic dissection is fatal without emergent repair (based on the stanford system)?
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type A
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besides for Type B, why else would surgery be required for pts with aortic dissection?
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if blood flow is compromised to the legs, kidneys or other viscera.
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what can prevent the growth of dissections and avoid aneurysms?
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tight BP control
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what areas does Raynaud's phenomenon mainly affect?
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toes and fingers
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what are the physical characteristics of Raynaud's?
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episodic bilateral digital pallor, cyanosis and rubor
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what relieves raynaud's?
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warmth
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what gender is more affected by Raynaud's?
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women
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what are the symptoms of raynaud's phenomenon?
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recurrent episodes of digital ischemia with characteristic white- blue-red color sequence
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what happens to the fingers inbetween attacks of raynaud's phenomenon?
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the fingers are completely normal
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what is the tx for raynaud's phenomenon?
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avoid cold temperatures
protect hands aspirin calcium channel blockers reduce frequency and severity of vasospastic episodes |
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what is Beurger's Disease? What age and gender is more commonly affected?
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A non-atherosclerotic disease of the small-medium-sized arteries, veins and nerves of the arms and legs affecting mostly young men before the age of 45 years.
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what is the cause of Buerger's disease?
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unknown.. all pts have a history of heavy tobacco addiction
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what are the symptoms of Buerger's disease?
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claudication of the feet, legs, hands or arms.
skin changes (ischemia, ulcerations) found mainly in the extremities |
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how do you diagnose Buerger's disease?
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clinical presentation and biopsy which will show inflammatory intramural thrombi within the arteries and veins
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what is the tx of buerger's disease?
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complete tobacco and nicotene abstinance!
- iloprost (reduces limb ischemia and improve healing) -surgical amputation required in >40% of those pts who do not quit smoking |
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what is considered a fever?
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100.4 F
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what is giant cell arteritis?
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inflammation of the lining of the medium-large arteries
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what type of vasculitis is giant-cell arteritis?
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large vessel
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T/F
Giant cell arteritis is immune-mediated |
true
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what age group is most directly affected by giant-cell arteritis?
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elderly >50 yoa (females>males)
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worst headache i'v ever had.
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subarachnoid hemorrhage
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what are the symptoms of giant cell arteritis?
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headache from temporal arteritis
jaw claudication from ischemia of masseteres visual loss due to ophthalmic artery dz |
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what would you see on PE for giant cell arteritis?
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sclap tenderness in the temporal artery area
pale edematous fundus |
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what studies prove giant cell arteritis?
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elevated CRP and sed rate (>50)
diagnosis confirmed by biopsy of arterial tissue |
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what is the tx for giant cell arteritis?
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high dose corticosteroids.
methylprednisolone |
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do you wait for the biopsy befre treating giant cell arteritis?
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NO!!
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what is takayasu's arteritis?
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Granulomatous vasculitis of the aorta, its main branches and the pulmonary artery.*
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Who is most commonly affected by takayasu's arteritis?
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young women of asian descent
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what is the most common sign of takayasu's arteritis?
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HTN
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what can the inflammatory process of takayasu's arteritis lead to?
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stenosis and/or aneurysm formation
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what can be found on physical examination for takayasu's arteritis?
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bruits over subclavian artery and aorta
diminished brachial pulses low brachial artery BP |
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how do you tx takayasu's arteritis?
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corticosteroids- 1st line
immunosuppressive agents- MTX |
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what is an arteriovenous fistula?
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Abnormal vascular communications which shunt blood flow from the arterial system directly into the venous system, bypassing the capillary beds that normally ensure optimal tissue perfusion and nutrient exhange.
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what are the symptoms of AV fistula?
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pulsatile mass, bleeding from spontaneous rupture, neurologic defiicts or seizures (If AVM is in the brain)
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how do you diagnose AV fistulas?
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MR, CT, Conventional angiography
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what is venous thromboembolic disease?
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The presence of coagulated blood, or thrombus in a vein. Encompasses both DVT (Deep Venous Thromboembolism) and PE (Pulmonary Embolus).
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what is the incidence of venous thromboembolic disease?
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1/1000 pts
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what is the virchows' triad?
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3 predisposing factors for venous thromboembolic disease
1. endothelial damage 2. venous stasis 3. hypercoagulation |
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what can cause endothelial damage?
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surgery or trauma
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what can cause venous stasis?
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prolonged bed rest or immobilization
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what can cause hypercoagulation?
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common with cancer and birth control pills
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what is Trousseau's syndrome?
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Migratory thrombophlebitis with noninfectious vegetations on the heart valves typically in the setting of mucin-secreting adenocarcinoma.
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what is diseases are included under hypercoagulable states?
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hereditary diseases such as deficiences in antithrombin III, protein C or protein S
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what are some etiologies for DVTs?
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surgery, immobility, birth control pills, atrial fibrillation, cancer, heart failure, pregnancy, venous catheters
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how far down do we go to search for DVTs with ultrasound?
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no lower than the popliteal artery
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where do most DVT's begin?
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in the calf
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what are the symptoms of DVT?
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pain and/or swelling!!!!
if in UE: superior vena cava syndrome and throacic outlet obstruction |
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what would you see on physical exam of DVT?
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Tenderness, erythema, warmth, and swelling below the site of thrombosis.
Pain with dorsiflexion of the foot (homan's sign) may be present |
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what is a highly sensitive indicator of DVTs? when would you use this indicator?
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D-dimer; use if your suspicions are low.
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how do you diagnose DVT?
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d-dimer (very non specific)
duplex US |
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what is the tx for DVT?
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1st- heparin (IV), or lovenox (SQ)
2nd- warfarin start after 1st meds |
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how would you tx and upper extremity DVT in young pts?
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consider thrombus removal by fibrinolytic infusion thru a catheter inserted directly into the affected vein or mechanical fragmentation of the thrombus
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when would consider giving an inferior vena cava filter?
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pts with proximal DVT who 1) either have an absolute contraindication to anticoagulation or 2) develop recurrent PE despite adequate anticoag.
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T/F
Inferior vena cava filter reduces the incidence of PE and the recurrent DVTs |
FALSE
they increase the risk of recurrent DVTs |
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when does a PE occur?
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PE occurs when a thrombus dislodges from the deep veins of the upper or lower extremities and embolizes to the arterial blood supply of the lungs where it then blocks a pulmonary artery.
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what are the symptoms of PE?
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sudden onset of dyspnea, pleuritic chest pain, anginal chest pain, hemoptysis and syncope
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pt comes into the ER complaining of chest pain, what MUST be on your diagnosis?
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PE
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what are the physical findings of a PE?
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tachypnea, tachycardia, crackles, wheezing, pleural rub
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how do you diagnose a PE?
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ABG- may reveal hypoxia
spiral CT of chest D-dimer (only use when index of suspicion is low) Spiral Chest CT angiography |
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what is the modality of choice to diagnose PE?
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spiral chest CT angiography
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how do you tx PE?
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anticoagulation-immediate!! IV Unfractionate Heparin
-warfarin after starting UFH -Thrombolytics reserve for pts with hypotension and/or severe hypoxemia |
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how long to we continue anticoagulation in PE pts?
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3 to 6 months after PE due to trauma or surgery.
-indefinitely for VTE due to cancer -Indefinitely for idiopathic VTE |
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who should be give venous thromboembolism prophylaxis to?
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surgical pts
hospitalized pts w/ acute illnesses (CHF, inflammatory disease, 3 days or longer of immobilization) |
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what does VTE prophylaxis involved?
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heparin, LMWH, pneumatic stockings, TED hose, early ambulation
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GOOD TO KNOW
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