Vascular Diseases

Vascular Diseases

Vascular Diseases

-Aortic Aneurysm

-Aneurysm refers to the focal dilation of an artery

-Aortic aneurysm can be thoracic or abdominal 

-Usually from atherosclerotic disease 

-Occurs more frequently in men

-HTN, Connective Tissue disease and Family History of Aneurysm are risk factors

-Most AAA are infrarenal 

-Diagnosis of Aneurysm can be made on ultrasound in abdomen

-Transesophageal ECHO (TEE) can diagnose Thoracic Aneurysms

-CT or MRI may be used to diagnose Aneurysm

-CT with IV contrast or TEE needed for dissection

-AAA >5 cm should be resected

-Iliac artery aneurysms greater than 3 cm should be resected

-May try percutaneously placed prosthetic grafts

-Pseudo-aneurysm 

-localized tear in arterial wall that allows blood to accumulate in the vascular space

-Comes from trauma to vessel

-More prone to rupture

-Need treatment

-Aortic Dissection

-Tear in the aortic intima layer through which blood accumulates and dissects between the intima and the media creating a false lumen

-CT with IV contrast or TEE needed for diagnosis

-Beta Blockers even in normotensive patients

-Emergent surgery is needed for Type A (Proximal) Thoracic Dissections 

-Expandable endovascular stents are sometimes used

-Larger dissections need to go for operative repair in the OR

-Arterial Embolism/Thrombosis

-Presents as sudden onset of pain involved extremity

-The P’s of arterial occlusion pain, pallor, paresthesias, paralysis, and pulselessness

-Emboli originate from the heart (A-Fib) or atherosclerotic changes of vessel

-Thromboectomy or Thrombolysis need to be don with ischemic extremity.  

-Can also place stent in certain areas

-Long term anticoagulation needed after revascularization 

-Thromboangiitis obliterans (Buerger’s Disease)-disease of small arteries and veins in upper and lower extremities

-Common <40 in heavy smokers

-Needs risk factor modification

-Giant Cell Arteritis

-may either present as Takayasu’s Arteritis or Temporal Arteritis 

-Takayasu’s Arteritis usually effects young women and likes to affect the aortic arch and the great vessels

-Treatment is systemic corticosteroids.  

-Surgery is rarely needed to bypass affected vascular bed

-Temporal Arteritis

-Temporal Arteritis is another type 

-Presents with temporal headaches and unilateral vision changes

-Presents in older patients

-ESR usually >100 mm/hr

-Definitive dx is biopsy. Treatment steroids 

-Peripheral Artery Disease (PAD)

-Defined as chronic occlusive artery disease

-Presents with pain in affected extremity with exertion alleviated with rest (Claudication)

-Ischemic foot ulcers and hair loss of affected extremity may occur

-Diagnosis duplex ultrasonography ABI < 1.0.  >1.0 is normal in health patients

-Treatment is usually conservative Pentoxifyline (vasodilation and decreased platelet aggregation) or Cilostazol  (vasodilation and decreased platelet aggregation)

-Treatment also involves risk factor modification (smoking cessation and weight loss)

-Revascularization when disabling symptoms, ischemic ulceration, gangrene, or acute arterial occlusion

-Phlebitis/Thrombophlebitis

-Thrombophlebitis is when there is inflammation of a wall of a vessel from a thrombus

-May involve superficial or deep veins

-Superficial thrombophlebitis produces a firm tender cord at affected vein

-Treatment for superficial involves warm compresses and NSAIDs

-Thromboembolic events do not occur with superficial because of valves and endogenous TPA produced by the body

-Venous Thrombosis 

-DVT usually affects the lower extremities but can affect upper or come from pelvis veins

-Virchow’s Triad-venous stasis, hypercoagulability, and venous injury predisposes to DVT

-Diagnosis is accomplished with ultrasound

-DVT

-DVT risk factors

-Pregnancy

-Surgery

-Malignancy

-Immobility

-Inherited Hypercoagulable States

-Trauma

-Lupus anticoagulant 

-Central Venous catheters

-Anticoagulation is initially accomplished with bolus of heparin or lovenox.  

-Warfarin is started then until INR is 2.0-3.0

-Warfarin is continued for 3-6 months

-Pregnancy requires lovenox.  No warfarin in that it crosses placental barrier

-Consider repeating doppler study prior to discontinue treatment

-Second DVT requires lifelong treatment and/or Greenfield filter

-Venous Insufficiency 

-Varicose veins caused by incompetent valves in the saphenous veins

-May result from conditions increase in abdominal pressure (pregnancy, ascites, obesity)

-Conservative treatment is TED hose

-Surgical vein stripping/sclerotherapy

-Leg ulcers or chronic venous stasis dermatitis may develop

-Right sided heart failure or cirrhosis may be predisposing factors

-Lymphedema is different in that is non pitting and from incompetent lymphatic channels