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: