On this week’s episode, we’ll be discussing vascular disorders. Please note that we’ll be discussing arteriovenous malformations in the neurology chapter.
Peripheral artery disease
PAD Picmonic Here!
* Pain in lower extremities increased with exercise, relieved with rest
* Called claudication
* Imagine angina for the legs
* Most commonly in the calf
* Physical exam
* Decreased pulses
* Decreased cap refill
* Atrophic skin changes
* Thin/shiny skin
* Hair loss
* Cool limbs
* Pale on elevation, dusky red with dependency (dependent rubor)
* Lateral malleolar ulcers with well-defined borders
* No artery on the lateral side
* Diagnosis
* Ankle-Brachial Index
* Ratio of BP at ankle compared to arm
* Lower BP in ankle=less blood flow=lower index
* Screening tool
* + if ABI <0.9
* Arteriography
* Gold Standard (because it SHOWS us occlusion)
* Usually only done in practice if revascularization planned
* Management
* Platelet inhibitors
* Cilostazol
* Useful for intermittent claudication
* ASA
* Clodpidogrel
* Exercise!
* Revascularization
* Angioplasty
* Fem-pop bypass
Acute Arterial Embolism
* Can be a complication of PAD
* Thrombus=originates at that spot embolus=originates elsewhere, then lodges
* 6Ps
* Paresthesias
* Pain
* Pallor
* Pulselessness
* Paralysis
* Poikilothermia
* Same as the 6Ps of compartment syndrome!
* Except these patients complain of paresthesias first (and different risk factors)
* “Cut off your circulation”=numb and tingly
* Compartment syndrome=squeeze tightly (like with a cast)=painful
* Tx: Heparin, Thrombolytics if thrombus, embolectomy if needed.
AAA
* >3.0cm
* Most often occurs infrarenally
* Risk Factors:
* Atherosclerosis #1
* Age >60
* Smoking!
* Male
* Connective tissue disorders
* Laplace’s law: larger aneurysms expand more quickly
* Symptoms:
* Often none
* Tender, pulsatile abdominal mass
* Rupture: severe back/abdominal pain, syncope, hypotension
* Diagnosis:
* Abdominal ultrasound
* Initial study of choice
* Used for monitoring (discussing in a minute)
* CT:
* thoracic aneurysms
* pre-surgical planning
* Angiography
* Gold standard (again, shows us a picture)
* Management:
* Beta blockers to decrease rupture risk
* 3-4cm: ultrasound Q1year
* 4-4.5cm: u/s Q6months
* >4.5cm: referral to vascular surgeon
* >5.5 cm or >0.5cm growth in 6 months: immediate surgical repair
Aortic Dissection
* Tear in the intima layer of the aorta
* Creates a false lumen
* Most often ascending (aortic highsections)
* Most fatal
* Risk Factors
* Hypertension
* Age 50-60
* Connective tissue disorders may present younger
* Symptoms:
