Cardiology 4

thoracic (ascending, arch, descending); Abdominal

Intima; Media; Adventitia

thin, inner layer (delicate, easily traumatized)

thick middle layer (*strength of the aorta comes from media)

somewhat thin outer layer (contains mainly collagen)

media (= laminated, intertwining elastic tissue/ multiple layers, in a spiral manner, max tensile strength w/ distensible & elastic

well defined collection of blood & conn tissue outside vessel wall

inflame = extreme of atherosclerotic aneurysm

multifactorial: genetic, environ, hemodynamic & immunological; Chlamydia pneumoniae?

infrarenal abdominal aorta

infrarenal abdominal aorta

stenotic obstrusion or aneurysmal dilatation

Saccular; fusiform

Fusiform

Fusiform

Saccular aneurysms

blood may stagnate along walls, cause mural thrombus (may embolize)

1.5x or > the normal diameter of the vessel.

Abdominal more common than thoracic aneurysm

<5cm (& 2/3 eventually require repair)

COPD pts: rupture of smaller AAAs more likely

aortic bifurcation (& often involve common iliac arteries)

80% rupture into left retroperitoneum (may contain it); remainder rupture into peritoneal cavity (=> uncontrolled hemorrhage & rapid circulatory collapse)

about 2 cm

> 3 cm

10:01

2%

dense athero-sclerosis, eroding & weakening the wall which leads to dilatation then rupture

below renal arteries (infrarenal); 10% suprarenal

stenosis (narrowing) of aorta

>5 cm*

HTN, hyperlipidemia, & atherosclerosis of coronaries & other arteries.

loss of elastin & increase in collagen (=> lack of distensibility)

Tobacco; Age; HTN; lipid; Atherosclerosis; Male; FH

1/4 of AAA pts have first degree relative with hx of AAA

Abdominal US:

100% sensitivity, no contrast, low cost

pre-op or if US indeterminate; better defines shape & location/ extent of AAA

underestimate diameter

Size (5cm female, 6 cm male); rapid progression (>1cm/yr); female; FH; unctrld HTN; SMK; COPD

Trend: bigger AAA, more frequent surveil

5.5 cm

Rapid expansion (>1 cm/yr) & pt preference (in 4.5-5.5 cm range)

endovascular repair at smaller diameters

4.5 or 5.0 cm

80% mortality with rupture

Risk factor mod (stop SMK, aggressive HTN & Lipid Rx), med mgmt to slow progression

Elective = 2-5%, Expanding = 5-15%, Ruptured: >50%

length: min 15 mm; diameter: max 28 mm; angulation: <60 degrees

Common iliac a.: variable diameters; ext iliac a. <7 mm

large AAA (> 5.5 cm) in men btw 65-75 w/ Hx of SMK; No gdln for men 65-75 no hx SMK; gdln against screen in women

All M 60-85; All F 60-85 w/ 1 or more CVD risk factor; M&F > 50 w/ FH AAA

Far less common than AAAs

pt of aorta involved ( ascending, arch or descending TA)

desc TA extends distally to involve AA

Less common than AAA w/ diff pathogenesis; 60% = aortic root & ascend A; 40% desc A; 10% arch

Cystic medial necrosis

ascending aorta

aortic wall weakening => fusiform aneurysm

aortic root & may consequently result in AI

HTN (occurs somewhat w/ aging)

conn tissue dz (Marfan, Ehlers-Danlos syndrome, RA); aortic valve replacement

CMN, Bicuspid valve; AI; Arteritis/ Vasculitis; Collagen vasc dz (RA, Marfan, Ehlers-Danlos, Reiter); HTN; Syphilis; Atherosclerosis

CMN

diffuse aortic atherosclerosis

aneurysms of asc OR desc A & can be caused by any of the etiologies above.

atherosclerosis

just distal to origin of L subclavian; may be fusiform or accular

Ext of Asc or Desc aneurysms; Hx trauma or deceleration injury

extend below level of diaphram into abd aorta

less common than AAA (bc inc of Sx due to compression of surrounding structures)

surgery (if Sx or rapid expansion: then sooner)

Inc incidence of rupture

> 50% pts ASx at dx; Sx due to vascular consequence or mass effect

AI with CHF, or thromboembolism causing stroke, lower extremity or mesenteric ischemia, renal infarct

SVC syndrome, tracheal deviation, cough, hemoptysis, dysphagia, hoarseness

SVC or innominate v. => obstruction of venous return

trachea or main stem bronchus => tracheal deviation, wheezing, cough & positional dyspnea, hemoptysis or recurrent pneumonitis

dysphagia & compression of recurrent laryngeal n. can cause hoarseness

Pain ( 25% pts) from direct compression of intrathoracic structures or chest wall; substernal or in back/ neck; steady, deep & severe?

excruciating pain; may be assoc w/ aortic dissection

L intrapleural space or mediastinum; results in severe hypotension

adjacent esophagus => life threatening hematemesis

CXR; Echo (TTE vs TEE); CT/ MRI

CXR NOT dx alone (need CT or MRI to r/out if CXR neg)

Must differentiate from anterior mediastinal mass (ie thymoma, lung CA)

coronary angiography

TTE only good to visualize aortic root (good for Marfan); TEE to visualize entire aorta, but is semi invasive (CT/ MRI better)

Size & rate of growth

2%

3%

7%

Marfan; bicuspid valve

≥ 5.5 cm (=/> 5.5)

≥ 5.0 cm (=/> 5.0)

≥ 4.0 cm (=/> 4.0)

≥ 6.0 cm (=/> 6.0)

Dacron graft w/ prosthetic valve sewn directly into aortic annulus; coronary arteries reimplanted into the graft (op mortality risk 5%)

valve sparing Bentall (re-implant native valve within dacron graft)

M&M higher than with AAA; 5 yr if unrepaired (>6 cm) is 20-25% (most deaths due to rupture or CAD)

8-20%

pulmo comps & damage to laryngeal or phrenic n., carotid or subclavian a. poss

3/100,00/yr (at least 7,000 cases/yr in the US)

antegrade (driven by the forward force of aortic blood flow); sometimes retro from site of intimal tear

aortic dissection

media & adventitia

May be acute or chronic

Ascend aorta just distal to aortic valve or just distal to L subclavian at lig arteriosum

65% Ascend A; 20% Desc A; 10% A Arch; 5% Abd A.

Men > women 2:1 (peak incidence 60-70 y.o.); 2,000-3,000 cases/yr

pregnancy (1/4 of all female cases <40 yrs & most in last trimester); conn tissue dz (Marfan, Ehlers Danlos); Bicuspid Aortic Valve or Coarctation

Hypertensive

Ascending A extending to distal

Ascending aorta only

Descending aorta only

Any involvement of ascending aorta

Not involving ascending aorta

DeBakey Types I & II or Stanford Type A

DeBakey Type III & Stanford type B

Acute: sudden, severe excruciating ripping chest pain (ascending) or scapular (descending); most hypertensive or nml

Pt appears to be in shock; pulse discrepancy or syncope (tamponade)

Acute aortic regurgitation (CHF indicates valve involvement); focal neuro (CVA may develop)

wide mediastinum, poss L sided pleural effusion

98% sensitive, 99% specific, +/- pericardial effusion, done bedside

acute presentation

serial follow up

LVH, nonspecific or inferior abnormalities (dissections preferentially extend into Right coronary ostium)

Wide aortic silhouette & mediastinum; Left pleural effusion; 10%-20% normal

Surgical repair, may require AVR

Medical therapy

Rupture, Limb/ visceral ischemia, Saccular morphology, ongoing pain, uncontrolled HTN, Marfan, AI

medical Rx

aggressive BP control; yearly imaging or if increased Sx

Op mortality of type B 2x that of type A (bc comorbid illness)

70-80% repaired type A

50-70% repaired type B

30% => progressively enlarging aneurysm that eventually requires repair

Atherosclerosis

Hx of intermittent claudication or rest pain

Aortoiliac disease

Common femoral artery

superficial femoral artery

Lower calf: popliteal artery

tibial/peroneal artery

Diminished peripheral pulses, femoral bruits, cool skin temp, abnormal skin color, poor hair growth

Intermittent Claudication; ischemic rest pain; ulceration; tTissue necrosis

mx pain in LE induced by exercise and relieved with rest; highly reproducible

pseudoclaudication of spinal stenosis (normal pulses/color)

Baker Cyst; Chronic compartment syn; Arthritis; Nerve root compression; Spinal stenosis; Venous claudication

1.0+ (blood pressure augments distally)

dx of peripheral vascular dz

intermittent claudication

rest pain

impending tissue necrosis

Risk factor mod; SMK cessation; Walking program; antiplt tx (aspirin & clopidogrel); Pletal Trental; revascularization (Surgery vs Stenting)

Asx PAD or mild to mod claudication

CLI (Critical Limb Ischemia) & amputation; wound healing; or to screen/ monitor

Pain; Pulseless; Pallor; Paresthesia; Paralysis; Poikilothermia

Embolism; Thrombus in situ

heart, aorta, large arteries

atherosclerotic plaque, trauma, hypercoagulable dz

Valvular dz or valvular prosthesis Ischemic dz (post MI/ plaque rupture); Paradoxical emboli from DVT of leg rarely produce emboli

the heart

present in 60-70% (thrombus forms in left atrial appendage)

Revascularization; IV heparin; Intra-arterial thrombolytic therapy; Surgical thromboembolectomy; Surgical bypass

Varicose V; Chronic Venous Insuff; Superficial Thrombophlebitis; DVT

Varicose Veins

venous valve incompetence & subsequent venous reflux from increased pressure

Asymptomatic to dull, aching pain or discomfort of legs usu worse after prolonged standing

50%-60% to LEs, 20% to cerebrovasc; 10-20% to UEs/ renal/ mesenteric circ

pregnancy

Secondary VV d/t: chronic venous insufficiency of deep vein; Retroperitoneal venous obstruction; Arteriovenous fistula; congenital venous malformation

Thrombophlebitis

Thrombophlebitis

pregnancy, local trauma, long periods sitting

ascends in trunk of Gr saphenous v. & leads to thrombosis of femoral vein

Graduated compression stockings (TED); Elevate legs; endovenous ablation (radiofrequency vs laser); sclerotherapy; greater saphenous vein stripping (older)

Functionally inadequate v. valves in LEs d/t bad leaflets (do not coapt)

post-thrombotic syndrome (scarred/thick) or dilatation of vein & unable to coapt

Hx DVT/ leg trauma; EDEMA (below knees); brawney skin pigmentation & venostasis ulcer (above ankles); pruritic, dull discomfort(esp w/ long standing)

LE edema d/t: CHF; chronic renal dz; decomp liver dz; Lymphedema (usually unilateral); Autoimmune; PAD

Grad compression stockings; avoid long stand/ sit; elevate legs; last: pneumatic leg compressions

Superficial Thrombophlebitis

long saphenous v.

PG, blunt trauma, IV infusion, thromboangitis obliterans, abd ca;

20% of cases

linear erythema, induration, & dull tenderness along affected vein

septic phlebitis (IV line)

cellulitis

Avoid prolonged standing

local heat & elevation, bed rest, NSAIDs; Sx usually resolve in 7- 10 days

Ligation surgery

Anticoagulation

usually benign & brief (Varicose v. etiology: recurrent)

20% (usu Staph (Antibx & vein excision)

extends to deep veins (potential for PE)

DVT

deep veins of the calf

femoral or iliac vein

Stasis, Vascular Injury, Hypercoaguable State

Long bedrest/ immobility (surg), long air travel, malignancy, nephrotic syndrome

50% Asx; dull aching pain in calf/leg, worse with ambulation; edema in affected limb, palpable cord, low grade temp, tachycardia; Homan sign 50% of time

3 points

3 points

1.5 points

1.5 points

1.5 points

1 point

1 point

makes dx highly unlikely

highly likely

D-dimer; LE Doppler/ US; if PE suspected, VQ scan versus spiral CT; hypercoaguable w/u if no identifiable predisposing event

negative result is helpful; pos results non-specific

Hep (vs LMWH) & concomitant warfarin loading; warfarin; Thrombolytic tx; embolectomy; IVC filter

(INR 2.0 – 2.5); idiopathic 6 mos 1st event; non-idiopathic or recurrent event: consider indefinite tx

PE; ischemic limb; varicose v.; chronic venous insufficiency

Minor surg in pt < 40 yrs w/ no additional risk factors

Minor surg in pt < 40yrs w/ an additional risk factor or surg in pt 40-60 years of age

Surgery in pt > 60 years or in pt 40-60 with risk factors

Surg in pt > 40 yrs w/ multiple risk factors or hip/knee arthroplasty or major trauma spinal cord injury

age, cancer, prior VTE, obesity, heart failure, paralysis, hypercoaguable state

Early ambulation, pneumatic stockings

SubQ unfract hep or LMWH +/- pneumatic compression

SubQ LMWH

No formal risk assessment; pneumatic compression stockings for low risk pts; unfract hep or LMWH for other pts w/ systemic illness limiting mobility esp w/ other risk factors