Peripheral Vascular Disease
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Cramping pain in specific muscle groups that occurs when blood flow is inadequate for meeting the demands of exercise.
Describe ulcers resulting from arterial insufficiency:
Involve the toes or plantar surface of the foot and are painful.
Describe venous ulcers:
Less painful, typically occur near the malleoli.
What does tissue necrosis in PVD signify?
Multilevel disease of the distal arterial tree
Chronic proximal occlusion alone is associated with the development of collateral circulation, which is normally adequate for preventing necrosis and gangrene.
Most common site of atherosclerotic occlusion in the lower extremities =
Distal superficial femoral artery.
The occlusion occurs in the adductor canal proximal to the popliteal fossa and is related to the anatomic relationship of the artery to the adductor magnus tendon at this site.
In PVD, impotence is caused by:
Occlusion of the hypogastric (internal iliac) artery, which reduces blood flow through the internal pudendal artery and corpora cavernosa.
What is Leriche syndrome?
Intermittend claudication of the thighs/buttocks, impotence, and diminished or absent femoral pulses indicative of aortoiliac atherosclerotic occlusive disease.
What is "blue toe syndrome"?
Emboli from atherosclerotic plaque in the aortoiliac vessels that may cause distal tissue necrosis even in the absence of occluding lesions.
Principal cause of death in patients with aortoiliac atherosclerotic occlusive disease is:
Coronary artery disease.
% per year of patients with intermittent claudication that progresses to gangrene:
What vessels does Raynaud syndrome affect?
Vasospasm of the small arteries and arterioles of the most distal portions of the extremities (i.e.: the hands, fingers, feet, and toes)
Regarding femoropopliteal bypass, patency rates are higher when performed for claudication or limb salvage?
Claudication because of the extent of the underlying pathologic process.
Name the classic signs of acute arterial occlusion (the five P's):
- absence of Pulse
What are the common causes of acute arterial occlusion?
Initial treatment of acute arterial embolus to the lower extremity with limb threatening ischemia =
IV 5000unit heparin bolus followed by continuous-drip administration
Gold standard for assessing completeness of thromboembolectomy =
- Restoration of distal pulses or Doppler signals
- Intraoperative arteriography when necessary
Most arterial emboli originate from:
The left atrium
Arterial emboli of cardiac origin most frequently produce occlusion of:
The common femoral artery.
Most common symptom of thoracic outlet syndrome =
Pain/paresthesia in the C8-T1 nerve distribution
What is Buerger disease?
inflammatory thrombosis of the small & medium-sized vessels of the upper and lower extremities
aka Thromboangiitis obliterans
associated with tobacco use
Rapid rewarming with warm water
Pt most commonly affected by popliteal artery entrapment syndrome =
men before age 40
What is post-thrombotic syndrome?
How often does it occur?
Valvular incompetence in deep veins below the knee and perforating veins following a DVT.
Occurs in up to 60% of patients following a DVT
When is it best to use TPA or Urokinase in the treatment of DVT?
Most effective when given to patients with DVT of less than 5-7 days duration
Best results in patients who have had symptoms for less than 48hrs.
Contraindicated within 4 weeks of major operations or injury.
What is phlegmasia cerula dolens?
Early thrombus removal can prevent progression to venous gangrene
Describe the Trendelenberg test for diagnosing venous insufficiency:
Two-part test used to delineate the competence of the superficial and perforating veins.
While supine, the patient elevates the legs until the superficial veins empty
- Part 1 - saphenofemoral junction is occluded digitally and the patient is asked to stand, superficial veins are observed for 30 seconds
- Positive Test = rapid filling, indicates incompetence of deep and perforating veins
- Part 2 - saphenofemoral occlusion released while the veins are kept under observation
- Positive Test = rapid retrograde filling, indicates incompetence of the valves of the superficial system
Describe the three types of primary lymphedema:
1. Congenital lymphedema (Milroy Disease if + family history)
2. Lymphedema praecox (Meige disease if + family history) - onset < 35yo, most common
3. Lymphedema tartda - onset >35yo
Acquired peripheral arteriovenous fistula treatment:
Percutaneous techniques such as detachable balloons and embolization.
What is Paget-von Schroetter Syndrome?
aka: axillary-subclavian vein thrombosis
Spontaneous, typically occurs in males following upper extremity exertion
Paget-von Schroetter Syndrome diagnosis:
Gold standard = venography
Indications for Inferior Vena Cava filter =
- Pts with contraindication to anticoagulation
- Recurrent PE/DVT despite anticoagulation
Paget-von Schroetter Syndrome treatment:
Catheter-directed thrombylysis and resection of first rib if patency is restored and venous narrowing demonstrated
Heparin-Induced Thrombocytopenia treatment:
Direct thrombin inhibitors such as Lepirudin & Argatroban
- Lepirudin depends on renal clearance
- Argatroban depends on hepatic functional status
Direct contrast-enhanced lymphangiography
Change in ABI in response to exercise for healthy vs. diseased patient:
- Healthy - ABI goes up
- Diseased - ABI goes down
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