VASCULAR DISEASE

COMPILED BY:

DR .A.R.HOGHOOGHI

PERIPHERAL ARTERIAL DISEASE

•REFERS MAINLY TO ATHEROSCLEROTIC DISEASE OF LOWER EXTRIMITIES ARTERY

•MORE IN MEN

•2% TO 6% IN YOUNGER THAN 60 AND 20-30% IN OLDER THAN 70

•MAJOR RISK FACTOR SMOKING .DM.HLP.HTN•30-50% ARE SYMPTOMATIC

MAJOR SYMTOPM: INTERMITTENT CLAUDICATIN

•REFERS TO ISCHEMIC PAIN OF MUSCLES ORWEAKNESS DUE TO EXERCISE AND

•RELEIVED BY REST

CLAUDICATION IS ASSOCIATED BY 10 YEAR RISK FOR MORBIDITY AND MORTALITY

•25% WORSENING OF CLAUDICATION

•5% NEED AMPUTATION

•10-20% REVASCULARISATION

•30% DIE OF CARDIOVASCULAR EVENT

RISK FACTOR MODIFICATION IS ABSOLUTLY ESSENTIAL

•DIAGNOSISI MADE BY HX AND EXAM •ISCHEMIC PAIN IN MUSCLES THAT ARE DISTAL

TO STENOSIS •CALF CLAUDICATION DUE TO FEMORAL AND

POPLITEAL STENOSIS •THIGH AND BOTTOCK AND HIP CLAUDICATION

DUE TO AORTOILIAC DISEASE •HAVE TO DIFFERNTIATE FROM SPINAL

STENOSIS (PSEUDOCLAUDICATION(

PHYSICAL EXAM

•ARE ABSENT OR DIMINISHED PULSES

•BRUIT OVER STENOSED ARTERY •HAIR LOSS

•THIN SHINY SKIN •MUSCLE ATROPHY

•SEVERE ISCHEMIA CAUSES PALLOR .CYANOSIS.COLD SKIN ,ULCERATION ,GANGEREN

NONINVASIVE TECHNIQUE ANKLE BRACHIAL INDEX (ABI)

•NORMAL ABI IS 0.9 TO 1.3•LESS THAN 0.9 INDICATE PAD

•SENSITIVITY AND SPECIFICTY 95% And 99%•IN DM AND CRF ID FALSELY ELEVATED

•SVERE PAD IS LESS THAN 0.4 AND >1.3 IS NONCOMPRESSIBLE VESSEL

•DUPLEX ULTRASOUND ADJUNCT TO ABI USEFUL IN NONCOPMPRESSIBLE VESSEL FROM MEDIAL WALL CALCIFICATION

OTHER NON INVASIVES ARE CT ANGI AND MR ANGIO.CATHETER BASED

ANGIOGRAPHY IS GOLD STANDARED RESEREVED FOR REVASCULARISATION

•MEDICAL MANAGEMENT :LIFESTYLE•ANTI PLT

•SMOKING CESSATION •LIPID LOWERING

•HTN CONTROL <140/90•ALI(ACUTE LIMB ISCHEMIA )CONSTITUTE A

VASCULAR EMERGENCY .SUDDEN OCCLUSION OF ARTERY BY EMBOLI IN CARDIAC CHAMBERS OR THROMBOSIS IN SITU

AORTIC ANEURYSM

•ABDOMINAL AORTIC ANEURYSM (AAA)IS A COMMON VASCULAR DISEASE IN OLDER ADULT

•4-8%MEN IN 0.5-1.5%IN WOMEN

•THORASIC ANEURYSM IS LESS COMMON

•BESIDE AGE MAJOR RISK FACTORS ARE SMOKING,HTN ,FAMILY HISTORY OF AORTIC ANEURYSM

ATHEROSCLEROSIS IS RESPONSIBLE FOR MOST CASE BUT MARFAN AND EHLER DONLOS .TAKAYASO.GIANT

CELL ARTERITIS ,SYPHLITIS ,TRAUMA

•AAA GRADUALLY GROW AVERAGE RATE OF 1 TO 4 MM PER YEAR

•RISK OF RUPTURE GROW OVER SIZE OF 5 CM

•MOST ARE ASYMPTOMATIC BUT SOME DEVELOP VASCULAR COMPERESSION

•MURAL THROMBI AND EMBOLI

•COMPERSSIO OF URETRA AND BLADDER AND SCIATIC NERVES

CLASSIC FINDING IS PULSATILE NONTENDER MASS BELOW UMBLICUS DISTAL TO ORIGIN OF

RENAL ARTERIES •ROUTIN SONOGRAPHY IS RECOMMENDED

FOR ALL MEN ABOVE AGE OF 65 AND 75 AND ABOVE AGE OF 60 WITH F.H OF AAA IN FIRST DEGREE RELATIVES

AORTIC DISSECTION

•INTIMAL LAYER THORN FROM THE AORTIC WALL LEADING TO THE FORMATION OF A FALSE LUMEN IN PARALLEL WITH TRUE LUMEN

•RISK FACTOR INCLUDE HTN .COCAINE USE ,TRAUMA ,MARFAN EHLERS DANLOS ,TAKAYASU BEHCET , BICUSPID AORTIC VALVE AND AORTIC COARCTATION

CAN BE CLASSIFIED TO TYPE A AND B

•TYPE A INVOLVES THE ASCENDING AORTA .TYPE B DISTAL AORTA (STANFORD SYSTEM )

•DEBAKEY SYSTEM TYPE I-II.III•TYPE I ALL OF AORTA

•TYPE II ONLY ASCENDING AORTA

•TYPE III ONLY DESCENDING

AORTIC FROM ASCENDING AORTA HAS HIGH MORTALITY 1 TO 2 % PER HOUR DURING FIRST

24 TO 48 HOURS

•PATIENT EXPERIENCE SEVER BACK OR CHEST PAIN OR BOTH ABDOMIAL PAIN OR SYNCOPE AND STROKE ARE COMMON

•RETROGRADE PROPAGATION OF DISSECTION CAN CAUSE PERICARDIAL TAMPONADE OR CORONARY DISSECTION

•CAN CAUSE AR WITH ACUTE PULMONARY EDEMA

PHYSICAL FINDING :PULSE DEFICIT ,MURMUR OF AR ,WIDE PULSE PRESSURE,

•TEE,CT ANGIOGRAPHY MRANGIOGRAPHY CONFIRMS DIAGNOSIS BY FINDING OF INTIMAL FLAP THAT SEPARATE TRUE LUMEN FROM FALSE LUMEN

•TYPE A IS UNIFORMLY FATAL WITHOUT EMERGENT SURGICAL REPAIR

•WITH SURGERY ,MORTALITY IS REDUCED TO 10% AT 24 HAND 20% AT 30 DAYS

•TYPE MUST BE MEDICAL

PNETRATING AORTIC ULCERS AND HEMATOMA

•BUERGER DISEASE•RAYNAUD PHENOMENON

•GIANT CELL ARTERITIS

•TAKAYASU•AVFISTULAS AND AVM

PULMONARY ARTERIAL HYPERTENSION

•IS CAUSED BY COMBINATION OF PULONARY VASOCONSTRICTION ,ENDOTHELIAL CELL OR SMOOTH CELL PROLIFERATION .INTIMAL FIBROSIS THROMBOSIS IN THE PULMONARY CAPILLARIES AND ARTERIOLES

•MILD PAH CAN BE ASYMPTOMATIC IN MORE ADVANCED COMPLAIN OF DYSPNEA CHEST PAIN ,SYNCOPE ,PRESYNCOPE

•.LEFT PARASTERNLA LIFT LOUD PULMONARY COMPONENT OF S2 ,PI ,TR HEPATOMEGALY ,PERIPHERAL EDEMA AND ASCITIS

MEAN ARTERIAL PRESSURE 25,PCWP UNDER 15,PVR >3 UNIT CONFIRMSM

DIAGNOSIS•Pulmonary arterial htn

•Pulmonary venous htn

•PAH DUE TO CHRONIC RESPIRATORY DISEASE OR HYPOXEMIA

•PAH DUE TO CHRONIC VENOUS THROMBOEMBOLISM

•PAH DUE TO MISCELLANEOUS DISORDERS AFFECTING PULMONAR DIRECTLY

VTE :BOTH DVT AND PTE

•ANNUAL INCIDENCE 1/1000•HIGHER IN MEN

•HIGHER IN AFRICAN AMERICAN AND WHITE THAN TO ASIAN AND HISPANICS

•VIRCHOW TRIAD :ENDOTHELIAL DAMAGE 2.VENOUS STASIS 3.HYPERCOAGULATION

•TROUSSEAU SYNDROM :MIGRATORY THROMBOPHELEBITIS WITH NONINFECTIOUS VEGATATION ON HEART VALVES IN ADENOCARCIONOMA

DVT

•MOST STARTS AT CALF VEINS ,WITHOUT TREATMENT 15 TO 30% OF THESE CLOTS PROPAGATE TO THE PROXIMAL CALF VEINS

•RISK OF PTE IS HIGHER IN PROXIMAL DVT THAN DISTAL

•SUBCLAVIAN AND AXILARY VEIN DVT CAN LEAD TO PTE

•BUT LESS COMMON

PAIN AND SWELLING ARE MAJOR COMPLAIN BUT LARGE NUMBERS ARE

ASYMPTOMATIC •UPPER EXTR DVT CAN LEAD TO SVC

SYNDROME•TENDERNESS,ERYTHEMA,WARMTH,SWELLING

BELOW•PAIN WITH DORSIFLEXION OF THE FOOT

(HOOMAN SIGHN )•LAB TEST :D.DIMER IN PATIENT WHOSE

PROBABILITY ARE LOW NEGATIVE DDIMER EXCLUDE DVT

DUPLEX SONORAPHY HAS GREATER SENSIVITY TO DETECT PROXIMAL DVT

•MRANGIGRAPHY

•TRADITIONAL VENOUS ANGIOGRAPHY

PTE•WHEN A THROMBUS DISLODGE FROM DEEP

VEINS PVR AND PA PRESSURE INCREASEFROM 2 MECHANISM

•1.ANATOMIC REDUCTION IN CROSS SECTIONAL AREA OF PULMONARY VASCULAR BED 2.FUNCTIONAL HYPOXIA INDUCED PUMONARY VASOCONSTRICTION

•PRESSURE OVERLOAD ON RV LEAD TO RV DILATION AND HYPOKINESIA TR

•WHEN PRESSURE IS VERY HIGH CAN COMPRESS CORONARS AND LEAD TO ISCHEMIA IN RV

IN ACUTE PTE V/Q MISMATCH AND REDISTRIBUTION OF BLOOD FROM OBSTRUCTED ARTERY TO LREGIONS OF LOWER V/Q CAUSE ARTERIAL HYPOXEMIA

•SUDDEN ONSET OF DYSPNEA AND PLEURETIC CHEST PAIN

•ANGINA CHEST PAIN FROM ISCHEMIA OF RV ,HEMOPTYSIS FROM PUMONARY INFARCTION

•SYNCOPE OR PRESYNCOPE •TACHYPNEA ,TACHYCARDIA ,RV

LIFT .INSPIRATORY CRACKLES,A LOUD P2 ,EXPIRATORY WHEEZING ,PLEURAL RUB

ABG REVEALS HYPOXEMIA AND RESPIRATORY ALKALOSIS AND HIGH

ALVEOLAR TO ARTERIAL O2 GRADIENT •HAMPTON HUMP

•WESTERMARK IN CXR•SINUS TACH AF PAS SVT S1 Q3 T3 AND NEW

RBBB AND RAD•POS D.DIMER

•D DIMER SHOULD NOT USE IN PATIENT HIGH PROBABILTY OF EMBOLI

•PERFUSION SCAN ,CT ANGIO AND ANGIOGRAPHY

•VASCULAR DISEASE

•COMPILED BY:

•DR A.R.HOGHOOGHI