Peripheral Vascular Disease
Resident Rounds
September 27th, 2001
Outline
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Cases
Pathophysiology
Acute Arterial Occlusion
Arterial Aneurysms
Vasculitidies
AV Fistulas
Thorasic Outlet Syndrome
Vascular Abnormalities Caused by Drug Abuse
Cases
• Case 1
– 70 male with known atrial fibrillation. Presents with a sudden
onset painful left arm for 2 hours. It is cold to the touch, the radial
pulse is difficult to palpate compared to the right and light touch is
decreased in the hand.
• Case 2
– 63 male with known IHD. Prseents with increasing abdominal
discomfort for 4 hours. No history of similar discomfort. He is
pale, tachycardic and BP 80/60.
• Case 3
– 2 girl with 5 days of fever, irritability and decreased appetitie. On
exam; cervical lymphadenopathy, red swollen lips and bilateral
purulent conjunctivitis.
Cases
• Case 4
– 55 woman c/o right sided headache for 2 days. Says her vision has
been intermittently affected. Has a history of migraines. Tender
over her right temporal region.
• Case 5
– 60 male with recent TIA, c/o sudden onset very painful left foot.
No preceeding trauma or history of same. On exam, left 1st toe is
cyanotic and tender to movement and touch. Posterior tibial and
dorsalis pedis pulses are present.
Pathophysiology
• 8 basic processes
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atherosclerosis
aneurysm
embolism
thrombosis
inflammation
trauma
vasospasms
fistula
Pathophysiology
• The Normal Artery
– intima -- endothelial cells
surrounded by
subendothelial connective
tissue
• endothelial tissue is an
important
thromboresistent layer
– media -- circular muscle
– adventitia -- nerve fibres
and vaso vasorum
Pathophysiology
Atherosclerosis -Aneurysm -Embolism -Thrombosis -Inflammation/Vasculitis -Trauma -Vasospasm -Fistula --
Pathophysiology
• Atherosclerosis
– disease of medium and large sized arteries
– lipid core, raised and focal plaque within the
intimal layers
– as plaques progress in size they further occlude
the artery lumen and will weaken the walls of
effected arteries
– can also rupte producing cholesterol emboli
Pathophysiology
• Aneurysm
– true and false aneurysms
– true -- focal abnormal dilation of intact vessel
wall
– false -- extravascular hematoma that
communicates with the intravascular space
– give rise to symptoms by following
mechanisms
– rupture and hemorrage; impingement on adjacent
structures; occlusion of vessel; embolism; pulsatile mass
Pathophysiology
• Embolism
– blood clot or foreign body carried to a site
distal from its point of origin
– most are a result of a detached thrombus
(thromboembolus)
– some from ruptured atheromas
Pathophysiology
• Embolism:
– Thromboembolus
• majority (85%) from heart
• left ventriculr thrombus from MI approx 70% of
these
• mitral stenosis and RHD present in approx 10%
• atrial fibrillation present in 75% of arterial embolic
events
Pathophysiology
• Embolism
– Atheroembolism
• micremboli consisting of cholesterol, calcium and
platlet aggregates
• bilateral symtoms -- aortic source; unilateral
symptoms -- distal source (femoropoliteal arteries,
60%, aortoiliac arteries, 40%)
Pathophysiology
• Embolism
– infectious emboli
• bacterial endocarditis can produce septic infartcts
can may evolve into abcesses
Pathophysiology
• Arterial Thrombosis
– formation of a blood clot within the vascular
system
– usually a result of atheromatous plaques which
cause endothelial injury and disturbed blood
flow.
Pathophysiology
• Inflammatory
– drugs, irradiation, trauma, bacterial invaision,
non-infectious
– Vasculidities
• inflammation and necrosis of blood vessel
• presentation depends on vessel size and location
– Infectious Arteritis
• most due to IV drug use or infective endocarditis
Pathophysiology
• Vasospasm
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Raynaud’s Disease
Raynaud’s Phenomenon
livedoreticularis
acrocyanosis
• due to abnormal vasomotor response in distal
vessels
• ischemic symptoms without tissue loss
Pathophysiology
• Atriovenous Fistulas
– abnormal communication between arterial and
venous circulations
• congenital; post-surgical; rupture of aneurysm;
penetrating injuries; inflammatory processes
• 60% associated with false aneurysms
Case 1
• 56 year old male presents with a sudden
onset painful left lower leg.
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Noticed it while working in the yard 1 hour ago.
Pain and tinlging sensation starts mid-thigh
wife says that his left foot is colder than the right
Further history?
• A Vascular History
– atherosclerosis is the major cause of PVD
Vascular History
• Secondary evidence of atherosclerosis
– IHD, MI, dysrhythmias (including a. fib), TIA,
CVA, renal disease
– Risk Factors
• DM, HT, high cholesterol, smoking,
• Past medical History
– DVT/PE, RF/valve disease, IVDU, autoimmune diseases, vasculitis
Physical Exam
• Systematic exam of the peripheral
vascular system
• Search for source of disease
(?embolus)
• can aid in differentiating embolic from
thrombotic events
Physical Exam
– Exam the area involved for appearance, colour,
temperature, motor and sensation. Compare to
the contralateral side.
– palpation of all pulses.
• where are they?
– 10% have absent dorsalis pedis
– exam extremities for;
• muscle bulk, hair distribution, skin appearance and
temperature
Physical Exam
• Neuro exam
– cranial nerves, cerebellar testing, peripheral
motor and sensation
• HEENT
– fundoscopy
– conjunctiva
– lymph nodes
Physical Exam
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Respiratiry
Cardiovascular
Abdomen
Peripheral
Physical Exam
Bedside Tests;
• blanch suspected area with finger pressure
– delay in return of normal colour suggests decreased
prefusion
• Buerger’s Sign
– patient supine. Feet elevated >1 feet above level of right
atrium and any colour change noted. If colour does not
change, patient dorsiflexes 5-6 times. Latent colour
change induced by exercise noted. Then the feet are hung
over the side of the stretcher. Normal colour should return
in 10 secs. Veins should fill in 15 secs. White on elevation
and hyperemic after 1min. of dependency suggests
advanced ischemia.
Physical Exam
• Allen’s
– evaluates patency of the distal radius and ulna arteries
Investigations
Non-invasive
• Doppler ultrasound
– more sensitive than palpation to detect pulses
– ankle vs brachial systolic BP (ABI)
• >20 difference suggestive
• Colour-coded Doppler
– assignment of colours to the direction of flow.
• Red is flow away from the probe; blue to.
Investigations
Invasive
• Contrast Angiography
– most definitive diagnostic test
– risk of the contrast against the benefits of the
procedure (mortality is 0.03%)
– indications;
• acute embolus or thrombus if diagnosis uncertain;
consideration being given to emerg. Bypass;
characterise the anatomy prior to surgery.
Case 1
• 56 year old male presents with a sudden
onset painful left lower leg.
– Noticed it while working in the yard 1 hour ago.
– Pain and tinlging sensation starts mid-thigh
– wife says that his left foot is colder than the right
Case 1
Differential
• Acute arterial occlusion
– thrombotic
– embolic
• Venous
– DVT
• Neurologic
• MSK
Acute Arterial Occlusion
Thrombus
Embolus
Cardiac
Source
valve
LV
Aneurysm
Non-Cardiac
Source
A. Fib
Arterial
Aneurysm
Acute Arterial Occlusion
• Embolus (85%)
– usually an identifiable source
– no history of progressive claudiaction
– few, if any, physical findings of occlusive
disease
– sources;
• cardiac -- left ventricle, valves: mitral or tricuspid, atrial
fibrillation.
• Non-cardiac -- arterial aneurysms, atherosclerotic plaques
Acute Arterial Occlusion
• Thrombosis
– usually superimposed on a chronic
atherosclerotic plaque
– unlikely to identify an embolic source
– history of claudication common
– will have physical findings of occlusive disease
• e.g. diminished pulses
Acute Arterial Occlusion
• Management
– A surgical emergency.
• Likelyhood of limb salvage decreases after 6 hours
of symptoms
Acute Arterial Occlusion
• Management
– Medical
• Anticoagulation -- IV heparin
– should be started in ED
– no studies have established any benefits with certainty
– relative contraindications; recent neurosurgery (<6weeks),
majore surgery <48hours ago, childbirth within <24hours,
thrombocytopenia, active bleeding.
Acute Arterial Occlusion
• Management
– Medical
• ?Thrombolytics
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not appropriate for limb threateneing ischemia
intra-arterial more effective than IV
.05 to .01mg/kg/hr tPA in experimental protocols
clot lysis usually takes 6 to 72 hours
successful reperfusion in 50%-85%
Intra-arterial Thrombolysis
DeMaioribus CA - J Vasc Surg - 1993 May; 17(5): 888-95
– IATT more suitable for thrombosis of native iliac or femoropopliteal
arteries and infrainguinal vein grafts.
Berridge DC - Br J Surg - 1991 Aug; 78(8): 988-95
– RCT comparing IA tPA, IV tPA and strepto.
• Initially successful lysis was significantly better in the IA group
• limb salvage at 30 days was higher in the IA group. NS.
TOPAS (Thrombolysis or Peripheral Arterial Surgery)
– RCT between surgery and urokinase in patients with acute
occlusion presenting within 14 days of onset. End-point was
amputation at 6 months. Study found no difference
Acute Arterial Occlusion
• Surgical Treatment
– Fogarty Balloon Catheter
– bypass grafting
– amputation
Case 2
• 35 male c/o 2 weeks of fever, weakness and
migrating joint pain.
– Abrupt onset of fever approx 24 hours after
routine dental cleaning. Chills and night sweats
present throughout.
Case 2
Case 2
Infective Endocarditis
• Further History
– Underlying heart disease
• acquired -- (70%) RHD, calcific stenosis, MVP, calcified
mitral annulus
• congenital -- VSD, PDA.
• Prosthetic material -- valves.
– Recent circumstances that may have resulted in a
transient bacteremia
• dental procedures; IVDU (2%-5%/yr); induced abortions;
IUDs, prolonged IV infusions; TTVP; endoscopic procedures.
Infective Endocarditis
Microbiological infection implanted on a
heart valve or mural endocardium
• Differential
– ABE
• meningococcemia
• DIC
– SBE
• ARF, SLE
Infective Endocarditis
• Microbiology
– Normal Valve
• 65 % streptococci (viridans, bovis and enterococcus)
• 10%-30% staph
– IVDU -- staphlococcal (80%), fungal, gram neg. and
polymicrobial.
– Prosthetic Valve -- coagulase negative s. aureus
Infective Endocarditis
• Physical Exam
– Fundoscopy
• petichial and flame-shaped hemorrhages in retina.
• Roth spots -- oval shaped hemorrhages surrounded
by zone of hemorrhage.
– Heart Sounds
• 66%-90% have murmurs; heart failure.
– Abdominal
• Hepatosplenomegaly
Infective Endocarditis
– Skin Lesions
• Janeway lesions -- hemorrhagic, non-tender
infarcted small lacules and papules on volar surface.
• Oslers Nodes -- tender, purpleish, subcutaneous
nodules in the pulp of fingers. Deposition of minute
infective emboli.
• Subungal splinter hemorrhages -- linear in middle
of nailbed
• petichial lesions -- small, non-blanching macules on
extremities, chest and conjuctiva.
Infective Endocarditis
• Investigations
– bloodwork
• CBC, ESR
• blood cultures
• complement levels, RF
– Imaging
• echo
• CT head?
– other
• urine analysis
• Management
– treat HF if present
– empiric antibiotics
• vanc and gent
– Disposition
Case 3
• 65 male with prior MI and 4 vessel CABG.
Presents with left sided calf discomfort for
four hours which started while he was
raking leaves.
– Pain moderately decreased when he stops
moving and sits; still able to ambulate but
increasingly uncomfortable.
– on exam -- cold feft foot with decreased posttibial pulse and a popliteal aneurysm
Peripheral Arterial Aneurysms
• Lower Extremity
– Popliteal (most common)
• bilaterally present in 60%
• abdominal aneurysm can be co-existent (upto 80%)
• aneurysm can cause venous compression and
subsequent DVT.
– Femoral
• presentation?
• Complications
– compression of femoral nerve -- ant. thigh pain
Peripheral Arterial Aneurysms
• Lower Extremity Aneurysms
– Investiagtions
• XR
– may show calcifications
• US and CT can demostrate the anbormal anatomy
• Arteriography is definitive
• evaluate for presence of other aneurysms
Peripheral Arterial Aneurysms
• Case 4
– 55 woman with right arm and shoulder pain for
2 weeks which is much worse today. New
onset hoarse voice this am. History of
intermittent lower leg claudication.
Subclavian Artery Aneurysm
Peripheral Arterial Aneurysms
• Upper Extremity Aneurysms
– Subclavian Artery Aneurysm
• Causes
– atherosclerosis
– trauma
– thorasic outlet obstruction
» compression of the subclavian artery at the superior
apex of the thorax. Due to an anatomic abnormality.
» very rare <1.0% of all cases of syndrome but the most
potentially serious.
Peripheral Arterial Aneurysms
• Upper Extremity Aneurysms
– Subclavian Artery Aneurysm
• clinical manifestations due to compression of
recurrent laryngeal nerve, trachea or brachial plexus
and reduced aterial flow.
Peripheral Arterial Aneurysms
• Upper Extremity Aneurysms
– Other UE aneurysms
• subclavian-axillary
– due to a rib abnormality which compresses the artery
• axillary artery
– due to prolonged and incorrect use of crutches
– all UE aneurysms can produce
thromboembolism and limb-threatening
ischemia. All require angiography.
Case 5
• 65 male with
headache, fever and
fatigue for 10 days.
This morning while
eating breakfast his
jaw began to ache
when chewing.
– Differential
– Other complaints
and/or findings to
note?
Vasculidities
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Classified by size of arteries involved
Large; Takayashu’s
Medium; Temporal arteritis
Medium and Small; PAN, Kawasakis
Small; HSP
Vasculitis
• Medium Sized Arteries
– Temporal Arteritis
• 90% over 60 years
• triad of fever, anemia and H/A in an elderly patient.
• Must recognize visual symptoms
– diplopia, blurred vision, ptosis
» if present visual loss due to optic nerve ischemia is
irreversible.
• Claudiciation of jaw due to stenosis of arteries
supplying the muscles of mastication.
Vasculitis
• Medium Sized Arteries
– Temporal Arteritis
• physical exam
– tender over course of
temporal artery
– CN exam important
– no findings of inc.
ICP or spaceoccupying lesion.
• Labs: ESR >100
Vasculidities
• Medium Sized Arteries
– Temporal Arteritis
• Management
– if suspected and
vascular
complications
impending begin IV
steroids
– if suspected without
vascular
complications may
treat as OP with po
steroids.
• Management
– biopsy of temporal artery
required for diagnosis
Case 6
• 12 year old boy with
fever, rash malaise and
weight loss for 2
weeks.
– Differential
– Physical exam findings
• MSK
• Fundoscopy
• Neurologic
Vasculidities
• Medium and Small
Vessels
– PAN
• multisystem necrotising
vasculitis. Renal and
visceral artery
involvement.
• Labs
– CBC,ESR ANCA
– urinalysis
• Other studies; lesion
biopsy, arteriography
Vasculidities
• PAN
– Management
• Hospital admission
• iv steroids and/or cytotoxic agents
Case 7
• 4 year old boy with
scrotal discomfort,
abdominal pain, rash
and refusing to walk.
Vasculidities
• Small Vessel
– HSP
• most common vasculitis in children
• characterised by
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periarticular, scrotal and scalp swelling
palpable, non-thrombocytopenic purpura
gastrointestinal bleeding (may develop intussusception)
nephritis (hematuria, proteinuria)
• Management; supportive; iv steroids not established.
Vasculidities
• Kawasakis
– acute, subacute and
convalescent stages
– diagnostic criteria (acute
phase);
• fever >5days
• redening of palms and
soles of feet
• bilateral conjunctival
injection and discharge
• red lips, strwberry tongue
• cervial lymphadenopathy
• diffuse exanthem
Kawasakis
• Complications
– Untreated -- 25%
coronary aneurysms,
thrombosis and MI and
subsequent HF
– Treated -- <5%.
• Management
– high dose aspirin
(100mg/kg/24hr) for
acute phase then low
dose aspirin.
Case 8
• 20 year old woman c/o bright red and hot
fingers, bilaterally. She recently finished a
day on the hill carving fat pow pow.
Vasospastic Disorders
• Abnormal and idiopathic vasomotor
response in the distal small arteries.
• Raynaud’s
– Disease -- bilateral symptoms (fingers turn white, blue then red)
precipitated by cold or emotion
– Phenomenon -- RD that occurs secondary to an underlying
condition eg connective tissue disorders. Features; asymmetric
involvement, ulcers and gangrene may be present.