Clin med-Peripheral Vascular Disease

•AAAs grow gradually _________________

(1 to 4 mm/year)

Aortic Dissection Type B:

-Treat medically because the 1-year survival rate is higher with medical therapy than with surgery (75% vs. 50%)

PAD: Dx •An ABI of _____ or less indicates PAD

0.9

•Chronic venous insufficiency with edema ~ ____% of men and 5% of women, and the prevalence increases with age

7.5

A previously healthy 68-year-old man with a 10 pack-year smoking history presents to the office for his annual exam. He had a normal colonoscopy last year and wants to make sure that he is up to date on his preventive health screenings. Which of the following health conditions should he be screened for? A. Abdominal aortic aneurysm B. Colorectal cancer C. Lung cancer D. Osteoporosis screening

A. Abdominal aortic aneurysm

An 82-year-old woman presents with two months of intermittent, atraumatic right leg pain. She states her pain comes when she tries to walk her dog down the street. The pain generally resolves after 10-15 minutes of rest but will start again after she starts walking. Which of the following is the most likely diagnosis? A.Chronic arterial insufficiency B.Chronic venous insufficiency C. Deep vein thrombosis D. Lumbosacral radiculopathy

A.Chronic arterial insufficiency

Which of the following is an indication for elective operative repair of an abdominal aortic aneurysm in asymptomatic patients? A. Aneurysm diameter more than 4.4 centimeters B. Aneurysm diameter more than 5.5 centimeters C. Aneurysm expansion of 0.4 centimeters in six months D. Aneurysm expansion of 0.5 centimeters in 12 months

B. Aneurysm diameter more than 5.5 centimeters

________________________ is the hallmark of femoral-popliteal disease

Calf claudication

Chronic Venous Disorders

Common Venous stasis--> blood pooling in the legs. Legs get brawny.

Management of venous insufficiency

Endovenous thermal ablation of saphenous veins

When is surgery indicated for AAA?

If over 5.5 cm in diameter

PAD ______________ pain occurs in the leg muscles supplied by arterial segments distal to site of stenosis

Ischemic

Evaluation of venous insufficiency note the extent of _________________.

Pitting edema

AAA

Pulsatile, nontender mass near umbilicus

Chronic Venous Insufficiency

Range from telangiectasias and reticular veins, to varicose veins, to chronic venous insufficiency with edema, skin changes, and ulceration

When is surgery indicated in Type B Aortic dissection:

Surgery is indicated if type B dissection compromises blood flow to the legs, kidneys, or other viscera •Tight control of BP is essential because aortic aneurysm develops in 30% to 50% of patients with type B aortic dissection studied for 4 years

How to confirm Aortic Dissection diagnosis?

TEE MRA CTA •intimal flap that separates the true lumen from the false lumen

Varicose veins More common in men or women?

Women •The estimated prevalence of varicose veins in the United States ~15% in men and 30% in women -Maybe due to childbirth. increased pressure on the veins

Aortic Aneurysm (AAA) Risk factors:

age, smoking, hypertension, family history of aortic aneurysms atherosclerosis

Debakey System Type 2

ascending aorta

Aortic Aneurysm (AAA) most patients are ___________________

asymptomatic

Peripheral Vascular Disease (PAD) Major reversible risk factors:

cigarette smoking diabetes mellitus hyperlipidemia and hypertension

Peripheral Vascular Disease (PAD) 30% will die of a cardiovascular event -->

concomitant CAD/CVD

Debakey System Type 3

descending aorta

Debakey System Type 1

entire aorta

Aortic Dissection Intimal layer is torn from the aortic wall -->

false lumen in parallel with the true lumen

Aortic Dissection Ascending aorta:

high mortality rate of 1% -2% per hour during the first 24 - 48 hours

Aortic Dissection Risk factors:

hypertension, cocaine use, trauma, hereditary connective tissue disease, vasculitis, bicuspid aortic valve, and aortic coarctation

Peripheral Vascular Disease (PAD) Intermittent claudication:

ischemic muscle pain or weakness brought on by exertion and promptly relieved by rest (leg angina

AAA: Management Repair:

large aneurysms or rapid aneurysm expansion regardless of size

PAD: management Smoking cessation reduces the risks of:

limb loss, myocardial infarction, and death

Peripheral Vascular Disease (PAD) more common in men or women?

men

PAD suspicion confirmed by:

noninvasive laboratory testing

PAD: Management Revascularization -->

severe claudication resistant to medical therapy, limb-threatening ischemia

PAD Management Rule out acute limb ischemia:

sudden onset, cold limb, medical emergency

AAA: Management how do you treat small aortic aneurysms:

treat medically, close monitoring with imaging studies every 6 -12 months

Aortic Dissection Type A:

uniformly fatal without emergent surgical repair •With surgery, mortality is reduced to 10% at 24 hours and 20% at 30 days

Management of venous insufficiency Pressures of 20-30 mmHg:

varicose veins; 30-40 mmHg may be required for patients with venous insufficiency, edema and ulcers

Varicose Veins Secondary varicose veins:

venous hypertension, associated with deep venous insufficiency or deep venous obstruction, and incompetent perforating veins that cause enlargement of superficial veins

• ~ 20% of patients with chronic venous insufficiency develop venous _________________.

venous ulcers •A venous ulcer is often shallow and characterized by an irregular border, a base of granulation tissue, and the presence of exudate

PAD: Dx Duplex ultrasonography:

•(looking for compressibility) in noncompressible vessels due to medial wall calcalcification, waveform

•The risk of aortic rupture:

•1% per year for aneurysms between 3.5 and 4.9 cm in diameter •5% per year for aneurysms larger than 5 cm

Peripheral Vascular Disease (PAD) •Prevalence increases with age

•2% to 6% for adults < 60 years •20% to 30% > 70 years

PAD: Management •Antiplatelet

•ASA or Clopidogrel (Plavix) or Ticagrelor (Brilinta)

Diagnostic tools for AAA:

•CT and MR angiography

Aortic Aneurysm (AAA)

•Common vascular disease in older adults •4% to 8% of men and 0.5% to 1.5% of women > 65

Varicose Veins

•Dilated, bulging, tortuous superficial veins, at least 3 mm in diameter

screening for AAA

•Duplex ultrasonography

in the evaluation of venous insufficiency you'll see?

•Hyperpigmentation, erythema, eczema

Venous Insufficiency

•Incompetent veins with venous hypertension and extravasation of fluid and blood elements into the tissue of the limb

PAD: Dx

•Magnetic resonance (MR) angiography •Computed tomographic (CT) angiography •Angiography reserved for patients undergoing revascularization.

AAA: Management

•Percutaneous endovascular repair vs open surgical

PAD: Management

•Regular walking (at least 30-45 minutes ≥ 3 times/week for ≥ 12 weeks

AAA: Management

•Smoking cessation, BP, lipid control

PAD: Management •Lifestyle and risk factor modification

•Statin, antihypertensive •Exercise training improves walking capacity and quality of life

Evaluation of venous insufficiency

•Visual inspection and palpation of the legs noting location and extent •Edema, stasis dermatitis, and skin ulceration near the ankle may be present if there is superficial venous insufficiency

Venous Insufficiency Primary:

•a consequence of an intrinsic structural or functional abnormality in the vein wall or venous valves leading to valvular reflux

PAD exam:

•absent or diminished pulses distal to the stenosis, bruits over the diseased artery, hair loss, thin shiny skin, and muscle atrophy •Severe ischemia causes pallor, cyanosis, decreased skin temperature, ulceration, and gangrene

Aortic Dissection presentation:

•acute onset of severe chest or back pain (TEARING back pain- boards question) •Abdominal pain, syncope, and stroke •Distal (type B) aortic dissection exhibit acute onset of back pain or chest pain, often accompanied by lower-extremity ischemia and ischemic neuropathy.

Aortic Dissection Exam:

•acutely ill patient with tachypnea, tachycardia, and a narrow pulse pressure, pulse deficits, neurologic deficits, or a diastolic murmur of aortic regurgitation

Aortic Dissection •Stanford System Type A:

•ascending aorta

Venous Insufficiency Secondary:

•caused by obstruction and/or valvular incompetence from previous deep vein thrombosis

PAD Management Percutaneous revascularization:

•comparable patency rate with less morbidity and mortality than surgery in patients with short, focal stenoses of large arteries (distal aorta or iliac arteries)

Aortic Dissection Stanford system Type B:

•distal aorta -more likely to have back and chest pain

Venous Insufficiency History:

•edema, achy, dull pain, throbbing worse after prolonged standing -cramping, burning, pruritus, leg swelling, and skin ulceration

Management of venous insufficiency Conservative measures:

•elevate legs, avoid prolonged standing, weight loss, compression stockings or stretch bandages

Varicose Veins risk factors:

•family history of varicose veins, aging, pregnancy, hormonal therapy, obesity, and prolonged standing

Findings of deep venous insufficiency include:

•include increased leg circumference, venous varicosities, edema, and skin changes

Management of venous insufficiency Surgical:

•ligation and stripping of the great and small saphenous veins.

PAD Management Surgical revascularization -->

•longer areas of stenosis or obstructive lesions distal to the origin of the iliac arteries

Who needs Routine screening for AAA: (ACC)

•men 65 - 75 years who have ever smoked •men > 60 years with a family history of AAA among first-degree relatives

PAD: Dx Ankle-brachial index (ABI):

•ratio of highest systolic BP measured from either dorsalis pedis or posterior tibialis artery to the highest systolic BP obtained from the brachial artery using a Doppler stethoscope

Varicose Veins Primary:

•superficial system from defective structure and function of the valves of the saphenous veins, intrinsic weakness of the vein wall, and high intraluminal pressure

Management of venous insufficiency Unna boots or low adherent absorbent dressings:

•take up exudates while maintaining a moist environment