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BRESSMAN

BRESSMAN. Peripheral Vascular Disease. Aneurysms. Causes: genetic, age (decrease elastin), atherosclerosis, inflammation, abn collagen metabolism Marfans: abnormal fibrillin Ehlers-Danlos: poor collagen Location matters: Central : tend to rupture Peripheral: thrombosis/embolism.

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BRESSMAN

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  1. BRESSMAN Peripheral Vascular Disease

  2. Aneurysms • Causes: genetic, age (decrease elastin), atherosclerosis, inflammation, abn collagen metabolism • Marfans: abnormal fibrillin • Ehlers-Danlos: poor collagen • Location matters: • Central: tend to rupture • Peripheral: thrombosis/embolism

  3. Thoracic Aortic Aneurysm • CXR shows widening of mediastinum • Expansion rate: 0.5 cm/year (the faster the rate, the more aggressive and dangerous the aneurysm is) • Clinical Signs: hoarse, non prod cough, CP, stridor, dysphagia, hemoptysis, hematemesis

  4. AAA • Don’t memorize all the numbers he gave you, just know that patients with AAA do NOT do well, and most of them die! • Feel widening (lateral pulsation) on sides of abd aorta = AAA • Severe abdominal/back pain if ruptured • Non ruptured- usu asymptomatic, discovered by palpation on routine exam • Indications for elective repair: • >5 cm, and >2 yr life expectancy • Enlarging >0.5 cm/year even if small aneurysm • Onset of sn/sxs- pain, embolization, ureteral obstruction

  5. Mesenteric Aneurysms: • Most common: splenic (4F:1M) • Embolic Occlusion: • Saddle embolus: at bifurcation of aorta into iliacs, collateral circulation may prevent problems • More distal the embolus, more likely you will lose tissue to necrosis (because less collaterals) • Embolectomy: mechanically remove thrombus • Thrombolysis: activate plasmin to lyse fibrin clot

  6. Mesenteric Insufficiency • 2/3 vessels effected (celiac, SMA, IMA) • Chronic: postprandial pain, wt loss, meandering mesenteric artery develops • Acute: absent BS, abd pain and WBC out of proportion to tenderness, septic and hypovolemic shock, need emergent embolectomy /revascularization

  7. Peripheral Vascular Arterial Insufficiency • Symptoms: intermittent/disabling claudication, rest pain, ulcers (tissue necrosis), gangrene of extremities • All due to inability to meet metabolic demands • DVT- due to venous stasis • Phlegmasia Albicans: venous obstruction resists arterial inflow—white leg • Phlegmasia Dolens: occlusive clot, blood can’t get out—blue leg • Can lead to PE • IVC filter indications: contraind/failure of anticoagulation, pelvic/long bone fxr, recurrent DVT • PE • Sxs: O2Sat<80% on RA, hemoptysis, + US of legs, + pulmonary scan

  8. Varicose Veins- due to incompetent valves, blood backs up and prolapses valves, high pressure blood is refluxed into surface veins • Compartment Syndrome: when tissue pressure in a confined space is great enough to impair venous blood outflow, this then impairs arterial inflow and reduces elimination of metabolic wastes, causes death of nerve tissue and ischemic muscle damage • End result is paralysis/fibrosis/contracture/dysfxn of limb • Causes: tight cast, crush injury, bites, emboli… • Sxs: pain on passive motion, cold, swollen, rigor, paralysis

  9. TIA- Transient Ischemic Attack • Lasts 2-15 minutes • Affects contralateral limbs • Precursor to strokes • Amaurosis Fugax – transient loss of vision, ipsilateral to lesion • Carotid US is best diagnostic tool to find occlusion/plaque • VertebroBasilar TIAS: any combo of motor/sensory dysfxn in extremities, vertigo/loss of balance, loss of vision • Know subclavian steal syndrome (If subclavian artery is occluded proximal to origin of vertebral, blood flow reverses direction (exacerbated by arm exercise which increases vertebral demand)—results in vertebrobasilar TIA symptoms

  10. Carotid Studies • Mild stenosis <50%: best to treat with medical therapy and serial duplex exams • Asymptomatic pts between 60-70% stenosis best treated with surgery

  11. That’s It For Bressman!

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