PVD

Question Answer
"Widened" in BP suggest what Large SV = increase in CAP (Contractility, afterload, preload)
A "Widened" Pressure can be exhibited in? Aortic Regurg, AV malformations, Athletes.
"Narrowed" in BP suggest Small/low SV.
A "Narrowed" BP can be exhibited in? shock, A. Stenosis, CHF, Tamponade.
Bifed/Bisferins pulse = beating two times in systole.
Bifed pulse can be exhibited by? Aortic insufficiency along with aortic stenosis, severe AI, HOCM
Dicrotic pulse= exaggerated, early diastolic wave. Conditions with low cardiac output and high systemic vascular resistance.
Pulse alternas = > 10 mm Hg drop in systolic BP during inspiration.
Pulse alternas can be exhibited in? Tamponade, pericarditis, and COPD/obstructive lung dz.
Abdominal Aorta must be examined in a patient of 70 years and older, with HTN.
Listen for bruits over abdominal aorta in the renal arteries, illiac arteries.
What is the number one valvular dz killer in US and worldwide Atherosclerosis "hardening of the arteries"
The tearing of the lumen allows what clotting cascade to activate. Side note: It causes worsening conditions in your patient.
A complication of atherosclerosis that causing a dilation of the aorta Aortic Aneurysm. > 3 cm. Normal dm in F -> 1.8 cm Nml dm in M-> 2 cm.
Risk factors for aortic aneurysm include? smoking, HTN. hyperlipidemia, obesity.
If your patients abdominal aortic aneurysm is 5 cm or larger it is most likley? Palpable. 80% of patients.
Elective surgery for Aortic Aneurysm is typically once its equal to or larger than 5 cm.
The diagnostic study of choice for initial screening f AAA is: abdominal US with routine f/u. Q2 years for those <4 cm. Q 6 months for those a 5 months.
Diagnostic study for a AAA that is 5 cm ? GET THAT CT !!! More accurately assesses size and determine anatomy., can visualize arteries above and below, need to visualize to repair it!
Patients with AAA can be asymptomatic or symptomatic. If patient is symptomatic: rupture. Excruciating abdominal pain that radiates to back, palpable mass, hypotension. Can be a contained or free rupture (slide 17).
There are two types of repair for AAA open and endovascular
The open repair is indicated for? younger patients. Older, sicker patient may not tolerate the stress of the proc.
Endovascular repair involves placement of what? stent-graft placement. Shorter recovery time, lower mortality rate. (slide 19-Photo)
What is the leading cause of death in patients with AAA MI
Thoracic Aortic Aneurysms can be due to atherosclerosis, connective tissue disorders, marfans syndrome, ehlers-danlos aneurysms.
S + S of Thoracic Aortic Aneurysms include: substernal neck or back pain, pressure on trachea, esophagus, SVC. stretching of L recurrent laryngeal nerve: hoarseness.
What is the study of choice for a thoracic aortic aneurysm? CT scan. MRI can also be used.
Treatment of thoracic aorta aneurysm includes? Descending aorta: Endovascular graft repair, shows good results.Arch and ascending: open repair in low risk pt by talented surgeon such a thor.
Is morbidity higher in AAA or TAA? TAA.
What is the most common aortic catastrophe? aortic dissection, caused by spontaneous intimal tear creates false lumen between media and adventitia
Aortic dissection is a true EMERGENCY. need IMMEDIATE control of BP to limit extent.
Risks of aortic dissection include HTN, Marfan syndrome, pregnancy, bicuspid aortic valve.
Aortic arch involvement of thoracic aortic aneurysm carries high risk of stroke, intellectual impairment, diffuse neuro injury. (The close to the head it gets the more neuro symptoms)
What type of dissection carries the worse prognosis? Type A = arch proximal to the left subclavian artery. Death within hours due to rupture into pericardial sac or dissection into coronary aa.
Type B dissection= proximal to descending thoracic aorta just beyond left subclavian artery.
A patient with aortic dissection will present with sudden, excruciating, ripping pain in the chest or upper back. Pain may radiate to abd, neck, or groin. Pt will be HTN initially then hypotensive.
In a patient with aortic dissection if you take their BP on both sides how would it present ? different on both sides. Good indicator of dissection
Immediate diagnostic imaging study of choice for aortic dissection is CT chest abd. ESPECIALLY IN ACUTE
For a chronic dissection you can order a MRI. CXR will show widened mediastinum.
Clinical pearl: A CXR with a widened mediastinum is Aortic dissection until proven otherwise.
Treatment for Aortic dissection includes: beta blocker to reduce LV ejection force, aggressively reduce BP and pulse. * Labetolol first choice. La beta lol's at dissections. Can use Esmolol IV for asthmatic pt, bradycardia. Nitroprusside IV if la beta not working.
If you have type A or type B dissection want to do emergent surgery.
Arterial embolism/Thrombosis can cause acute limb ischemia
Most emboli arise from Afib secondary to POOLING. Can also arise from valvular dz, ischemic heart dz, MI
Emboli can travel to? Extremities (most common), Cerebrovascular, upper extremities, mesenteric and renal circulation
The 6 P's are and are in relation to? of acute ischemia: Pain, Paresthesias, Pallor, Pulselessness, Poikilothermia, Paralysis.
For arterial embolism or thrombosis imaging studies to do? Doppler on the vessels. Can also order angiography, MRA, CTA (demonstrates abrupt cutoff of contrast).
Treatment of arterial embolism/thrombosis immediate symptom onset. Irreversible tissue damage at 6 hours. Used unfractionated heparin IV, Endovascular techniques (catheter directed chemical thrombolysis: Tpa), Throboembolectomy.
Other Acute arterial occlusions are occlusive cerebrovascular dz, visceral artery insufficiency "intestinal angina".
In the absence of Afib 90% of emboli originate from proximal interna carotid artery. Bruits would be heard loudest at mid neck, absence of bruits does not exclude carotid stenosis.
What imaging/screening modality of choice would your order for CVD Duplex US.
Treatment of occlusive CVD Carotid endartarectomy (CEA). carries risk of stroke. common complication: cutaneous sensory or cranial nerve injury.
Patients who have fully recovered from TIA or stroke will benefit from CEA
Giant cell Arteritis is also known as Temporal Arteritis and involves most commonly the temporal artery. Affects medium and large sized vessels in those > 50 years. 50% also have polymyagia rheumatica.
A patient presents with HA, scalp tenderness, she states has vision changes and throat pain this pt most likely has? Giant cell arteritis.
Labs in a pt with Giant cell arteritis show ESR > 50 mm/h, CRP may be nml, mild normochromic, normocytic anemia, thrombocytosis, elevated alk phos.
Gold standard diagnostic study of GA is? temporal artery biopsy (for dx)
Treatment of GA include? Prednisone 60 mcg/day orally immediately. Thoracic aneurysm screening
The development of occlusive atherosclerotic lesion in the extremities is PAD
Risk factors of PAD Include? male gender, smoking, increasing age, HTN, DM.
A patient with a hx of smoking, HTN, and DM presents with claudication in the ED he most likely has PAD
A patient has loss of hair, thinning skin, reduced popliteal and pedal pulses on exam this patient most likely has? PAD of the femoral-politeal segment. Other PE findings: muscle atrophy, foot gangrene or ulceration.
A patient has pain or numbness of foot with walking, ulceration of toes, and pallor when foot is elevated PAD most likely of tibial segment. May not have claudication.
Imaging for PAD is necessary ONLY when symptoms dictate intervention: Angiography, CTA, MRA
Treatment of PAD involves: aggressive risk factor reduction (smoking cessation, lipid reduction, weight loss, consistent moderate exercise), phosphodiesterase inhibitors Cliostazol 100 mg BID, antiplatelet inhibitors.
PAD can be treated with endovascular techniques and surgical interventions such as angioplasty and stenting. prosthetic bypass grafts, autogenous saphenous vein bypass, thromboendaterectomy, amputation.
A pt with PAD and DM would have the poorest prognosis
Phlebitis/thrombophlebitis affects most commonly the long saphenous vein.
Risks of phlebitis include short -term venous catherization, varicose veins, pregnancy or post-partum, trauma, abd ca.
Induration, redness, tenderness along superficial vein palpable and firm at site is most likely superficial vein thrombosis. *Extremity edema is uncommon. Can occur secondary to IV line placement.
Treatment of Superficial vein thrombosis involves anticoag if DVT present. For localied local heat and NSAIDS will suffice.
If superficial vein thrombosis involves extensive induration or progression toward saphenofemoral or cephalo axillary junction can treat with vein litigation and division of junction.
treat septic superficial vein thrombosis with AGGRESSIVE TREATMENT! Heparin, IV abx, possible surgical excision of vein
Most common vein involved in varicose veins saphenous vein
Varicose veins can be caused by incompetent or congenitally absent valves, any condition that causes increased intra abdominal pressure, any condition that interferes with venous drainage from the lower extremities.
Pt presents with dull, achy, heaviness, fatigue in lower extremities brought on by periods of standing in anatomy lab Varicose veins
Brownish pigmentation and thinning skin above ankle indicates? Varicose veins
What imaging can your order for varicose veins? Duplex US. Identifies the source of venous reflux that feeds the symptomatic vein, demonstrates incompetent valves and malformations, required for surgical intervention.
The treatment of varicose veins if symptomatic surgery (radio frequency ablation and/or stab avulsion, vein stripping). Compression sclerotherapy for small varicose veins < 4 mm diameter
Virchow's Triad = Stasis, vascular injury, hyercoagulability
Risk that lead to DVT recent surgery or trauma, malignancy, OCP use, Sedentary lifestyle, travel, immobilization.
Patient present with unilateral leg swelling and tenderness of the calf muscles the patient most likely has DVT
Can determine DVT with more accurately Calf circumference if swollen leg is > 3 cm than the other calf. Homans sign as well not as accurate.
How do you treat a DVT? anticoag's, IVC filter if anticoag's is contraindicated.
Preferred initial treatment for DVT is? LMWH: Enoxaparin (lovenox). Unfractionated heparin can be used in patients with kidney dz. Co-administer or bridge to warfarin for prolonged therapy.
Stasis pigmentation associated with chronic venous insufficiency is ? brown hemosiderin skin hyperpigmentation
Stasis dematitis, also associated with chronic insufficiency= tough, fibrous subcutaneous tissue.
Stasis ulceration, associated with chronic insufficiency= painless, large, wet, irregular slow to heal.
Treatment for chronic venous insufficiency includes Unna boot, ACE wrap, wet-to-dry saline dressings, hyperbaric chamber for wound treatment.
Buergers disease is also known as thromboangiitis obliterans present in males < 40 years of age smokers, with extremity vessels. *distal most arteries with inflammation (plantar and distal vessels)
Raynauds' dz is associated with C(calcinosis; ca deposits on skin) R(Raynauds phenomenon) E (esophageal dysfunction) S (sclerodactyly) T (telangiectasis) syndrome
Pulseless dz = Takayasu dz. Asian females , 40 years of age aortic arch dz.
How would you diagnose Buergers dz? MRA or angiography.
Treatment of Buergers dz? smoking cessation.
"blue-white-red" dz Raynauds phenomenon.
Secondary form of Raynauds can be caused by rheumatic diseases (especially scleroderma) can cause gangrene.
The first line therapy of Raynauds dz is Ca channel blockers. Nifedipine. amlodopine. —> failure: sympathectomy (effective for primary NOT secondary).