On this week’s episode, we’ll be discussing vascular disorders. Please note that we’ll be discussing arteriovenous malformations in the neurology chapter.

Peripheral artery disease

PAD Picmonic Here!

* Pain in lower extremities increased with exercise, relieved with rest

* Called claudication

* Imagine angina for the legs

* Most commonly in the calf

* Physical exam

* Decreased pulses

* Decreased cap refill

* Atrophic skin changes

* Thin/shiny skin

* Hair loss

* Cool limbs

* Pale on elevation, dusky red with dependency (dependent rubor)

* Lateral malleolar ulcers with well-defined borders

* No artery on the lateral side

* Diagnosis

* Ankle-Brachial Index

* Ratio of BP at ankle compared to arm

* Lower BP in ankle=less blood flow=lower index

* Screening tool

* + if ABI <0.9

* Arteriography

* Gold Standard (because it SHOWS us occlusion)

* Usually only done in practice if revascularization planned

* Management

* Platelet inhibitors

* Cilostazol

* Useful for intermittent claudication

* ASA

* Clodpidogrel

* Exercise!

* Revascularization

* Angioplasty

* Fem-pop bypass

Acute Arterial Embolism

* Can be a complication of PAD

* Thrombus=originates at that spot embolus=originates elsewhere, then lodges

* 6Ps

* Paresthesias

* Pain

* Pallor

* Pulselessness

* Paralysis

* Poikilothermia

* Same as the 6Ps of compartment syndrome!

* Except these patients complain of paresthesias first (and different risk factors)

* “Cut off your circulation”=numb and tingly

* Compartment syndrome=squeeze tightly (like with a cast)=painful

* Tx: Heparin, Thrombolytics if thrombus, embolectomy if needed.

AAA

* >3.0cm

* Most often occurs infrarenally

* Risk Factors:

* Atherosclerosis #1

* Age >60

* Smoking!

* Male

* Connective tissue disorders

* Laplace’s law: larger aneurysms expand more quickly

* Symptoms:

* Often none

* Tender, pulsatile abdominal mass

* Rupture: severe back/abdominal pain, syncope, hypotension

* Diagnosis:

* Abdominal ultrasound

* Initial study of choice

* Used for monitoring (discussing in a minute)

* CT:

* thoracic aneurysms

* pre-surgical planning

* Angiography

* Gold standard (again, shows us a picture)

* Management:

* Beta blockers to decrease rupture risk

* 3-4cm: ultrasound Q1year

* 4-4.5cm: u/s Q6months

* >4.5cm: referral to vascular surgeon

* >5.5 cm or >0.5cm growth in 6 months: immediate surgical repair

Aortic Dissection

* Tear in the intima layer of the aorta

* Creates a false lumen

* Most often ascending (aortic highsections)

* Most fatal

* Risk Factors

* Hypertension

* Age 50-60

* Connective tissue disorders may present younger

* Symptoms: