Transcript VASCULAR DISEASE

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
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 •