Give the normal diameter/length of the different sections of the Aorta:

- Ascending Aorta

3 cm diameter

5 cm long

Descending Thoracic Aorta

2.5 cm diameter

20 cm long

Abdominal Aorta (ends @ 2 cm below umbilicus)

2 cm diameter

15 cm long

At what rate due normal aneurysms enlarge?

0.5 cm per year

Why does an increased vessel radius lead to further widening?

T=PR

If you increase the radius initially, it also increase the tension on the vessel walls. Thus the increased tension causes a further expansion.

The dilation that occurs with an aneurysm is primarily due to a weakness of what part of the vessel wall?

Tunica Media

What are some of the most common aneurysm risk factors?

Atherosclerosis (not a cause, but associated)

family Hx

HTN

advancing age (>70)

male

CT disease (Marfan's/Ehler's Danlos)

Bicuspid Aortic Valve

3rd Trimester of Pregnancy

Cystic Medial Necrosis

What are two prerequisites for a dissecting aneurysm?

Systemic HTN

Tunica Media degeneration

What is the most common aneurysm and where does it usually occur?

Abdominal Aortic Aneurysm (AAA)

-below the level of the renal arteries (arteriosclerotic in etiology)

What is the size threshhold for an AAA that we can no longer just follow over time without the immediate need for surgical repair?

< 5 cm

AAAs are often asymptomatic but can also cause what Pt complaint?

- low back discomfort

- abdominal pain

- signs of embolization in the lower extremities

Why is just palpating for an AAA on a physical exam not sufficient in diagnosing a person at risk?

- Only 80% of people with an AAA great than 5 cm have a palpable AAA.

- Up to 78% of people with an AAA lack a pulsatile mass

What is a possible associatied symptom that could occur with an AAA in approximately a third of the cases?

Systolic bruit on auscultation

What associated problems occur with an aneurysm of the ascending aorta?

Aortic Regurgitation (AI) due to the separation of the valve cusps and distortion of the aortic annulus

Despite being the least common of the aortic aneurysms, an aortic arch aneurysm has what associated signs and symptoms?

- dyspnea (shortness of breath) -->bronchi/trachea

- hoarseness --> Recurrent Laryngeal

- Hemoptysis --> Trachea

- tracheal tug (up and down of L mainstem bronchus with each heart beat)

- Unequal pulses in each arm

The most common thoracic aortic aneurysm, descending thoracic aortic, has two primary symptoms. What are they?

- Chest pain in the back between the scapula

- Hemoptysis

Dissecting aneurysms of the thoracic aorta produce what associated signs and symptoms?

- excrutiating, tearing, anterior chest pain

- pain intensifies with each beat

- loss of peripheral pulses

- ischemic neurologic symptoms

- hoarseness (Rec. Laryng.) <--> Horner's syndrome

- CHF from acute aortic regurgitation

- cardiac tamponade

How are dissecting thoracic aorta aneurysms classified?

Whether they include the ascending aorta or not.

Type I or A --> involves ascending aorta (surgery)

Type III --> descending aorta only (no surgery)

What is the most common cause of an acute arterial occlusion?

atherosclerotic plaque dislodging and migrating downstream (to a smaller vessel)

Where do most (non-pulmonary) emboli come from?

Mural (wall) thrombi in the heart

- A-fib (atrium)

- MI (ventricle)

What are the 5 P's related to the signs and symptoms of sudden arterial occlusion?

-Severe PAIN

- PALLOR or lack of color distal to occlusion

- loss of peripheral PULSES distal to occlusion

- PARESTHESIAS from sensory nerve ischemia

- PARALYSIS or muscle weakness

What is the serious tissue problem with prolonged vascular occlusion?

Necrosis --> Organ infarction or Gangrene

- causes 'blue to syndrome'

- occlude the smaller digital arteries of the toes

- do not affect the larger pulses of the feet

- toes are blue or purple in color when the foot is in the dependent position

- pain can occur

Microemboli

What is a crampy muscle pain that develops in a limb during exercise as a result of ischemia?

Intermittent claudication

What is the most commonly affected vessel in chronic arterial occlusion and what is its most common symptom?

Superficial Femoral Artery

Calf Muscle Claudication

A decreasing amount of exercise requires to cause intermittent claudication suggests what?

The severity of the vascular obstruction is increasing

If a patient presents with buttocks or thigh pain and has risk factors that point to chronic arterial occlusion, which arteries are most likely to be occluded?

Aortic or Iliac

Total arterial occlusion, in chronic arterial occlusion and intermittent claudication, has what type of pain?

'Rest pain' that occurs all the time, even at rest

Erectile Dysfunction (vasculogenic impotence) is a possible symptom of chronic arterial occlusion. What specific syndrome is it usually associated with?

Leriche syndrome (bilateral aorto-iliac occlusive disease)

What are the primary physical findings associated with chronic arterial occlusion?

- absence of both pedal pulses

- cutaneous ulcerations and foot sores

- presence of a limb bruit

- pallor or cyanosis

- delayed capillary filling (> 5 seconds)

- atrophy of calf muscles

- systolic bruits

- ankle-brachial index (<.97)

Why is an absence of both pedal pulses not a full-proof way to predict vascular occlusion?

12% of the population has a congenital absence of one or both dorsalis pedis pulses

5% of African-Americans have congenital absence of posterior tibial pulse

0.5% of general population has congenital absence of both

What are some examples of the trophic influences that can occur with a gradual decrease in arterial supply due to vascular occlusion?

thinning/increased shinyness of skin

loss of hair

thickening of toe nails

cutaneous ulcerations

gangrene

What is common problem with diabetic patients in relation to the lower extremities?

- nerve damage --> neuropathic ulcers

In addition to being extremely rare on the soles of the feet, venous ulcers are primarily found where on the body? Also, what are some associated problems?

Venous ulcers are primarily found above medial malleoli and below the knee.

Associated problems are edema, varicose veins, increased cutaneous pigmentation

What does the ankle brachial index measure and how is the test performed?

It measures the systolic blood pressure in the ankle and the arm. The doctor puts a cuff around the Pt's calf and listens at the dorsalis pedis or posterior tibial arteries. The foot pressure is then divided by the arm pressure. <0.97 is cause for concern.

What are some important factors of the history that are relevant to people with/suspected of chronic arterial occlusion?

-type and location of pain

- aggravating/alleviating factors

- other causes for extremity pain (trauma, tumors, venous blood clots, infections)

Cerebrovascular Disease (CVD) essentially has what four main processes by which the end result (stroke) can occur?

- Hemorrhage (Hemorrhagic stroke)

- Embolization

- Thrombosis

- Vasospasm (hardest to treat/most deadly)

What are the primary causes of embolization in the heart?

- A-Fib

- mural thrombosis following MI

- mitral valve prolapse

- infective endocarditis

How would you distinguish between a carotid artery bruit and a transmitted cardiac murmur?

Bruits would be the most intense in the neck while murmurs would be the most intense over the chest.

An asymptomatic carotid bruit does what to a 35 year olds rick for stroke? For a 75 year old?

Increases it 3x

Normal (increased) risk

Why should care be taken when palpating a carotid bruit in someone at risk of a CVD or athersclerosis?

Atherosclerotic plaque could be dislodged.

What does TIA stand for and how long does it last?

Transient Ischemic Attack

< 24 hours

How does a stroke or TIA present?

weakness of contralateral face, arm, and leg

sensory impairment over same area

transient monocular blindness on ipsalateral side

contralateral homonymous hemianopia

dizziness, dysarthria, diplopia

What does the term idiopathic mean?

unknown cause

Raynaud's phenomenon progresses with what color changes?

White, Blue, Red (pain)

What are the common causes of the vasospastic disease Raynaud's phenomenon?

Lupus, Scleroderma, occupational trauma, occlusive arterial disease, drugs

What is the most common trigger for vasospastic attack related to Reynaud's phenomenon?

Exposure to cold or emotional stress

What vasospastic disorder causes a lacy or fishnet appearance of the lower limbs most likely due to a vasodilation of capillaries and venules?

Livedo reticularis

What vasospastic condition presents with cold and clammy skin with a bluish color primarily found in fingers and toes of infants?

Acrocyanosis

A 37-yr old painter presents with pain in the shoulder and arm with intermittent tingling and numbness that is amplified when she works on her current project, a roadside mural. All other exam/tests are normal. What is the primary differential?

a thoracic outlet syndrome

What does Adson's maneuver consist of and what gives a positive result?

While palpating the radial artery on the suspected (thoracic outlet syndrome w/ Scalenes) side, the pt holds a deep inspired breath and turns the head with chin raised toward the involved side. If the radial pulse becomes diminished or is lost, the test is positive.

How would a doctor test for a possible coracoid impingement thoracic outlet syndrome?

When the pt's arm is raised, a positive test would reveal a diminished or lost radial pulse.

What can be done to identify a thoracic outlet syndrome caused by a first rib and clavicle?

Pulling the shoulders back and down to decrease the thoracic outlet and assessing the radial pulse

Although an x-ray is the only way a cervical rib can be confirmed, what other physical assessment could suggest that one is present and causing a thoracic outlet syndrome?

Adson's manuever

What is the most common site of partial occlusion that causes a subclavian steal syndrome?

on the left, just proximal to the vertebral artery branch point of the subclavian artery

On physical exam, what are common findings with subclavian steal syndrome?

-bp & pulse are diminished in the affected arm

- systolic bruit is heard over the supraclavicular fossa

What disorder can cause vertigo, ataxia, lightheadedness, slurred speech, confusion, and hemiparesis brought on by exercise of the upper limbs?

Subclavian Steal Syndrome

What is the Allen test used for?

To test the patency of the radial and ulnar arteries and the palmar arch, usually in preparation for an arterial puncture of the radial artery

What happens on a normal Allen test?

After the radial and ulnar arteries are compressed and the hand is clenched, the ulnar artery is released and the hand returns to its pink color due to blood flow through the ulnar artery and the palmar arch.

What does the spreading pattern of varicose veins tell us about the origin of the problem?

Hereditary varicose veins progress from the thigh downward

Venous Thrombosis varicose veins progress from the lower leg to the thigh

What are the precipitating factors for varicose veins?

Obesity, pregnancy, cirrhosis of the liver, RV failure, high heels, DVT

What are the three components of Virchow's triad that contribute to the development of venous thrombosis?

- Venous stasis (sluggish venous circulation)

- Endothelial damage (trauma)

- Hypercoagulability (malignancy, surgery, pregnancy)

What are the two primary complications of a DVT?

Pulmonary embolism (PE) ==> usually from the popliteal or superficial femoral veins

Chronic venous insufficiency of the limbs

When taking a history of a pt who has a suspected DVT, what presenting symptoms and risk factors would they typically have?

- pain or swelling of the lower extremity (usually one leg)

Risk Factors

- FHx of clotting problems

- prolonged immobility

- recent trauma

- cancer

What are the two supplemental tests that are done on pt's with suspected DVT's after a careful physical exam and Hx?

Compression ultrasound and D-Dimer test

What is the most common vein affected by a superficial venous thrombosis?

Saphenous vein

Venous hypertension can occur as a result of chronic venous insufficiency (valvular problems) and result in what mostly cosmetic problem?

Varicose veins

A pt presents with a brownish (brawny) coloration of the skin just above the medial malleolus. What is a cause and potential complication of this finding?

- breakdown of hemoglobin and deposition of hemosiderin

- can cause ulceration, pruritis, and trauma from scratching (all combined into stasis dermatitis)

What is the most common cause of superior vena cava obstruction?

Mediastinal tumor/lung cancer

What are some of the presenting vascular symptoms of lung cancer/mediastinal tumors?

cyanosis and edema of the head, neck, and arms

elevated JVP

venous distension of facial veins

sublingual veins

conjunctiva (chemosis)

What is the primary indicator on a physicla exam of inferior vena cava obstruction?

presence of dilated superficial veins with cephalad flow below the umbilicus

What are the possible causes of inferior vena cava compression leading to obstruction?

retroperitoneal lymphadenopathy, aortic aneurysm, massive hepatomegaly