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IM - DISEASES OF THE VASCULATURE

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tonystep1's version from 2017-08-30 04:09

DISEASES OF THE VASCULATURE CLINICAL FEATURES

Question Answer
Hypertensive Emergency1. Severe headache
2. Visual disturbances
3. Altered mentation
4. systolic BP > 220 and diastolic BP > 120 in addition
to end-organ damage-immediate treatment is indicated.
Aortic Dissectionl . Severe, tearing/ripping/stabbing pain, either in the anterior or back of the chest
(often the interscapular region)
2. Diaphoresis
3. Most are hypertensive, but some may be hypotensive
4. Pulse or BP asymmetry between limbs
5. Aortic regurgitation
6. Neurologic manifestations (hemiplegia, hemianesthesia) due to obstruction of
carotid artery
Abdominal Aortic Aneurysm (AAA)l. Usually asymptomatic and discovered on either abdominal examination or a radiologic
study done for another reason
2. Sense of "fullness"
3. Pain may or may not be present-if present, located in the hypogastrium and
lower back and usually throbbing in character
4. Pulsatile mass on abdominal examination
impending Abdominal Aortic Rupturea. Sudden onset of severe pain in the back or lower abdomen, radiating to the
groin, buttocks, or legs
b. Grey Turner's sign (ecchymoses on back and flanks) and Cullen's sign (ecchymoses
around umbilicus)
Peripheral Vascular Disease IPVD) (Chronic Arterial Insufficiency) symptomssymptoms
a. Intermittent claudication
Cramping leg pain that is reliably reproduced by same walking distance (distance
is very constant and reproducible)
• Pain is completely relieved by rest.
b. Rest pain (continuous)
• Usually felt over the distal metatarsals
• Often prominent at night-awakens patient from sleep
• Hanging the foot over side of bed or standing relieves pain-extra perfusion
to ischemic areas due to gravity
• Rest pain is always worrisome-suggests severe ischemia such that frank
gangrene of involved limb may occur in the absence of intervention
Peripheral Vascular Disease IPVD) (Chronic Arterial Insufficiency) signsSigns
a. Diminished or absent pulses, muscular atrophy, decreased hair growth, thick
toenails, and decreased skin temperature
b. Ischemic ulceration (usually on the toes)
• Localized skin necrosis
• Secondary to local trauma that does not heal (due to ischemic limb)
• Tissue infarction/gangrene in end-stage disease
c. Pallor of elevation and rubor of dependency (in advanced disease)
Acute Arterial Occlusionsymptoms
l. Pain-acute onset. The patient can tell you precisely when and where it happened. The
pain is very severe, and the patient may have to sit down or may fall to the ground.
2. Pallor
3. Polar (cold)
4. Paralysis
5. Paresthesias
6. Pulselessness (use Doppler to assess pulses)
Cholesterol Embolization Syndrome• It is often triggered by a surgical or radiographic intervention (e.g., arteriogram), or by
thrombolytic therapy.
• It presents with small, discrete areas of tissue ischemia, resulting in blue/black toes,
renal insufficiency, ancl!or abdominal pain or bleeding (the latter is due to intestinal
hypoperfusion).
Mycotic AneurysmAn aneurysm resulting from damage to the aortic wall secondary to infection
• Blood cultures are positive in most cases.
Luetic Heartcomplication of syphilitic aortitis, usually affecting men in their
fourth to fifth decade of life. Aneurysm of the aortic arch with retrograde extension
extends backward to cause aortic regurgitation and stenosis of aortic branches, most
commonly the coronary arteries.
Deep Venous Thrombosis (DVT)l . Clinical presentation may be subtle.
2. Classic findings (all have very low sensitivity and specificity) :
a. Lower-extremity pain and swelling (worse with dependency/walking, better
with elevation/rest)
b. Homans' sign (calf pain on ankle dorsiflexion)
c. Palpable cord
d. Fever
Chronic Venous Insufficiency (CVI) (Venous Stasis Disease)l. Swelling of the lower leg
a. When chronic, causes an aching or tightness feeling of the involved leg; often
worse at the end of the day
b. Symptoms are worsened by periods of sitting or inactive standing.
c. Leg elevation provides relief of symptoms (the opposite is true in arterial
insufficiency) .
2. Chronic changes include:
a. Skin changes
• Skin becomes thin, atrophic, shiny, and cyanotic.
• Brawny induration develops with chronicity.
b. Venous ulcers
• Usually located just above the medial malleolus
• Often rapidly recur
Superficial Thrombophlebitisl . Pain, tenderness, induration, and erythema along the course of the vein
2. A tender cord may be palpated
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DISEASES OF THE VASCULATURE CAUSES

Question Answer
Hypertensive Emergencyl. Noncompliance with antihypertensive therapy
2. Cushing's syndrome
3. Drugs such as cocaine, LSD, methamphetamines
4. Hyperaldosteronism
5. Eclampsia
6 . Vasculitis
7. Alcohol withdrawal
8. Pheochromocytoma
9. Noncompliance with dialysis
Aortic Dissectionl . Predisposing factors
a. Longstanding systemic HTN (present in 70% of patients)
b. Trauma
c. Connective tissue diseases, such as Marfan's and Ehlers-Danlos syndrome
d. Bicuspid aortic valve
e. Coarctation of the aorta
f. Third trimester of pregnancy
Abdominal Aortic Aneurysm (AAA)l. Multifactorial-In most cases, there is atherosclerotic weakening of the aortic wall.
2. Other predisposing factors include trauma, HTN , vasculitis, smoking, and positive
family history.
3. Syphilis and connective tissue abnormalities (e.g. , Marfan's disease)
Peripheral Vascular Disease IPVD) (Chronic Arterial Insufficiency)Usually have coexisting CAD (with CHF, history of Ml, and so on)
and other chronic medical problems (e.g., diabetes, lung disease)
Risk factors
a. Diabetes-prevalence is markedly increased in these patients
b. Smoking, coronary artery disease, hyperlipidemia, HTN, hyperhomocystinemia
Acute Arterial Occlusionl . Acute occlusion of an artery, usually caused by embolization. The common
femoral artery is the most common site of occlusion. Less commonly, in situ
thrombosis is the cause.
2. Sources of emboli
a. Heart (85%)
• AFib is the most common cause of embolus from the heart.
• Post-MI
• Endocarditis
• Myxoma
b. Aneurysms
c. Atheromatous plaque
Cholesterol Embolization Syndrome• This syndrome is due to "showers" of cholesterol crystals originating from a proximal
source (e.g., atherosclerotic plaque), most commonly the abdominal aorta, iliacs, and
femoral arteries.
• It is often triggered by a surgical or radiographic intervention (e.g., arteriogram), or by
thrombolytic therapy.
Mycotic AneurysmAn aneurysm resulting from damage to the aortic wall secondary to infection
Luetic HeartA complication of syphilitic aortitis, usually affecting men in their
fourth to fifth decade of life. Aneurysm of the aortic arch with retrograde extension
extends backward to cause aortic regurgitation and stenosis of aortic branches, most commonly the coronary arteries.
Deep Venous Thrombosis (DVT)l. Cause: Virchow􀃩 triad (endothelial injury, venous stasis, hypercoagulability) gives
rise to venous thrombosis
2. Risk factors
a. Age >60
b. Malignancy
c. Prior history of DVT, PE, or varicose veins
d. Hereditary hypercoagulable states (factor V Leiden, protein C and S deficiency,
antithrombin III deficiency)
e. Prolonged immobilization or bed rest
f. Cardiac disease, especially CHF
g. Obesity
h. Major surgery, especially surgery of the pelvis (orthopedic procedures)
i. Major trauma
j. Pregnancy, estrogen use
Chronic Venous Insufficiency (CVI) (Venous Stasis Disease)a. History of DVT is the underlying cause in many cases (such a history might not
be documented).
Superficial Thrombophlebitisl. Virchow's triad is again implicated (but pathophysiology not entirely clear)
2. In upper extremities, usually occurs at the site of an IV infusion
3. In lower extremities, usually associated with varicose veins (in the greater saphenous
system)-secondary to static blood flow in these veins
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DISEASES OF THE VASCULATURE TREATMENT AND MANAGEMENT

Question Answer
Hypertensive Emergencya. Reduce mean arterial pressure by 25% in l to 2 hours. The goal is not to immediately
achieve normal BP, but to get the patient out of danger, then reduce BP gradually
b. If severe (diastolic pressure > 130) or if hypertensive encephalopathy is present,
IV agents such as nitroprusside, labetalol, or nitroglycerin are appropriate.
c. In patients who are in less immediate danger, oral agents are appropriate.
Options include captopril, clonidine, labetalol, and diazoxide.
2. Hypertensive urgencies: BP should be lowered within 24 hours using oral agents
Aortic Dissection Type Al. Initiate medical therapy immediately.
a. lV ,B-blockers to lower heart rate and diminish the force of left ventricular
ej ection
b. IV sodium nitroprusside to lower systolic BP below 1 20 mm Hg
2. For type A dissections-surgical management
Aortic Dissection Type BFor type B dissections-medical management
l. Initiate medical therapy immediately.
a. lV ,B-blockers to lower heart rate and diminish the force of left ventricular
ej ection
b. IV sodium nitroprusside to lower systolic BP below 1 20 mm Hg
Abdominal Aortic Aneurysm (AAA) unrupturedl. Unruptured aneurysms
a. Management largely depends on size of aneurysm
• If the aneurysm is >5 em in diameter or symptomatic, surgical resection
with synthetic graft placement is recommended. (The infrarenal aorta is
replaced with a fabric tube.) The diameter of the normal adult infrarenal
aorta is about 2 em.
• The management of asymptomatic aneurysms <5 em is controversial. Periodic
imaging is recommended to follow up growth. No "safe" size exists,
however, and small AAAs can rupture.
b. Other factors to consider are the patient's life expectancy (patient may be more
likely to die of other medical illnesses), and the risk of surgery
Peripheral Vascular Disease IPVD) (Chronic Arterial Insufficiency)l. Conservative management for intermittent claudication
a. Stop smoking (the importance of this cannot be overemphasized) . Smoking is
linked to progression of atherosclerosis and causes vasoconstriction (further
decreasing blood flow).
b. Graduated exercise program: walk to point of claudication, rest, and then continue
walking for another cycle
c. Foot care (especially important in diabetic patients)
d. Atherosclerotic risk factor reduction (control of hyperlipidemia, HTN, weight,
diabetes, and so on)
e. Avoid extremes of temperature (especially extreme cold).
f. Aspirin may be helpful.
g. Trental (pentoxifylline) lowers blood viscosity (improving blood flow)-more
studies needed to establish its role in treatment.
Peripheral Vascular Disease (with rest pain)• Surgical bypass grafting-this is the most common procedure and has a
5-year patency rate of 70% (immediate success rate is 80% to 90%) .
• Angioplasty-balloon dilatation
Acute Arterial Occlusiona. Skeletal muscle can tolerate 6 hours of ischemia; perfusion should be reestablished
within this time frame.
b. If paralysis or paresthesias are present, amputation is probably necessary.
2. Immediately anticoagulate with IV heparin.
3. Emergent surgical embolectomy is indicated via cutdown and Fogarty balloon.
Bypass is reserved for embolectomy failure.
4. Treat any complications such as compartment syndrome that may occur.
Cholesterol Embolization SyndromeTreatment is supportive. Do not anticoagulate. Control BP. Amputation or surgical
resection is only needed in extreme cases
Mycotic AneurysmTreatment: IV antibiotics and surgical excision
Luetic HeartTreatment: IV penicillin and surgical repair
Deep Venous Thrombosis (DVT)l. Anticoagulation
a. Prevents further propagation of the thrombus
b. Heparin bolus followed by a constant infusion and titrated to maintain the PTT
at 1 .5 to 2 times aPTT
c. Start warfarin once the aPTT is therapeutic and continue for 3 to 6 months.
Anticoagulate to INR at 2.0 to 3.0.
d. Continue heparin until the INR has been therapeutic for 48 hours.
Deep Venous Thrombosis (with massive P E , patients who are hemodynamically unstable, those with evidence of right heart failure)Thrombolytic therapy (streptokinase, urokinase, tissue plasminogen activator
[ t-PA J )
a. Speeds u p the resolution o f clots
Chronic Venous Insufficiency (CVI) (Venous Stasis Disease) (ulcer prevention)l. Before the development of ulcers, strict adherence to the following controls stasis
sequelae in most patients.
a. Leg elevation: periods of leg elevation during the day and throughout the night
to a level above the heart.
b. Avoiding long periods of sitting or standing.
c. Heavy-weight elastic stockings (knee-length) are worn during waking hours
Chronic Venous Insufficiency (CVI) (Venous Stasis Disease) (with ulceration)a. Wet-to-dry saline dressings (three times daily)
b. Unna venous boot (external compression stocking)-best changed every week
to 10 days
• Healing occurs in 80% of ulcers. Compliance reduces the rate of recurrence.
• For ulcers that do not heal with the Unna boot: Apply split-thickness skin
grafts with or without ligation of adjacent perforator veins.
Superficial Thrombophlebitis (localized)l. No anticoagulation is required-rarely causes PE
2. Localized thrombophlebitis-a mild analgesic (aspirin) is all that is required in most cases; continue activity
Superficial Thrombophlebitis (severe)a. Bed rest, elevation, and hot compresses
b. Once symptoms resolve, ambulation with elastic stockings is recommended.
c. Antibiotics usually are not necessary unless the process is suppurative, in
which case adequate drainage is indicated
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DIAGNOSIS OF DISEASES OF THE VASCULATURE

Question Answer
Aortic Dissection CXRl. CXR shows widened mediastinum (>8 mm on AP view) .
Abominal radiographs of AAAAbdominal radiographs a. May show calcifications of the dilated segment (this allows measurement of
aortic diameter)
AAA test of choiceUltrasound
What is the ABI for healthy personNormal ABI 2: 1 .0
What is the ABI for a patient with claudicationClaudication ABI < 0.7
What is the ABI for a patient with rest pain from PVDRest pain ABI <0.4
What is the workup for Acute Arterial Occlusionl. Arteriogram to define site of occlusion
2. ECG to look for MI, AFib
3. Echocardiogram for evaluation of valves, clot, MI
What is the initial test for DVT?Doppler analysis and Duplex ultrasound
What is the most accurate test for diagnosis of DVT of calf veinsVenography
What is the most useful test to rule out DVT ?D-Dimer
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