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VascularDiseases

AnkletoBrachialIndex(ABI)

>1.3

Noncompressiblevesselsduetocalcifiedarteries(ex:DM)

0.91.3

Normal

<0.7

Claudication

<0.4

Restpain
RatioofsystolicBPattheankletothesystolicBPatthearm

ArterialDisease

ChronicArterialInsufficiency
(PVD)

Occlusiveatherscleroticdiseaseofthelowerextremities

Risks:
Smokingdiabetesatherosclerosis
Sites:
Superficialfemoralartery(inHunterscanal)#1
Poplitealartery
Aortoiliacocclusivedisease(Lerichesyndrome)
Sx:
Intermittentclaudication
Calfonlyinsuperficialfemoralandpoplitealarteries
Buttox,hip,calfinaortoiliacocclusivedisease
Diminishedpulses
Smooth/shinyskinlossofhairandsweatglands
Restpainatnighthangfootoffbedforrelief
Ischemiculcersgangrene/necrosis
Dx:
ABI<0.9
Tx:
STOPsmoking
Cilostazol
Aspirin
Surgery
Pentoxifylline

AcuteArterialOcclusion

Embolizationofcommonfemoralartery

Risks:
afibendocarditisatherosclerosis
Sx:

(5Ps)

Pain(acuteonset)
Pallor
Polar(cold)
Paralysis
Paresthesias
Pulselessness

Arteriography

ImmediatelyanticoagulatewithIVheparin
Emergentembolectomyviacutdown
Fogartyballooncatheter

Dx:
Tx:

Sx:

CompartmentSyndrome

5Psofarterialocclusion
Indicationsforemergentfasciotomy:
Deltapressure=diastolicbpcompartmentpressure
Deltapressure<30
Compartmentpressure>40

VenousDisease

ChronicVenous
Insufficiency

HistoryofDVTvalvesdestroyedbecomingincompetentcausinggravitational
buildupandalackofpassageoutofsuperficialveinsintodeepveins

Risks:
previousDVT
Sx:
AmbulatoryvenousHTN
Edemarelievedbyelevationoflowerextremity
Brawny(brownblack)skinpigmentationfromextravasationofRBCs
Venousulcersdevelopmediallyabovemedialmalleolus
Skinbecomesthin,atrophic,shiny,cyanotic
Achy/tightnessworseatendofthedayandwithsitting/inactivestanding
Ulcersarelesspainfulvsarterialinsufficiency
Dx:
Clinical
Tx:
Legelevation
Compressionsocks
Unnavenousboot
Splitthicknessskingraft

Superficial
Thrombophlebitis

Virchow'sTriad:
Endothelialinjury
Venousstasis
Hypercoagulability

Locations:
Upperextremities:siteofIVinfusions
Lowerextremities:varicoseveins(greatersaphenousvenoussystem)
Sx:
Painandtenderness
Induration
Erythemaalongthecourseofthevein
Atenderpalpablecord
Dx:
Clinical
Tx:
Mildanalgesic(aspirin)
Bedrestandelevation
Hotcompresses
Monitorforriskofcellulitis
NOanticoagulationneeded(lowriskofPE)

DeepVenous
Thrombosis

Risks:
Virchowstriad
age>60
malignancy
prolongedimmobilization
hypercoagulablestates
majorsurgeryortrauma
cardiacdisease
pregnancy/estrogenuse
Sx:
Usuallyasymptomatic
Lowerextremitypainandswelling(worsewithdependency)
Homanssign
Palpablecord
Fever
Dx:
DopplerDuplexUS:proximalthrombi(poplitealandfemoral)
Venography:distalthrombi(calf)
Impedanceplethysmography:proximalthrombi
DDimertesting:usedtoruleoutDVT
Complications:
PE
Chronicvenousinsufficiencyin50%ofcases
Phlegmasiaceruleadolens:
severelegedemacompromisesarterial
supplyimpairedsensoryandmotorfunction
Tx:
Anticoagulationfor612months(goalINR=23)
Thrombolytictherapy:speedsupresolutionofclotsandisindicatedinPE
withhemodynamicinstability
ProphylacticIVCFIlter(GreenfieldFilter):ifwarfarincontraindicated
Prophylaxisaftersurgery:pneumaticcompressiondevices

WellsScorefor
PE

Pts

Clinicalsigns/symptomsofDVT

PEmostlikelydx

Tachycardia>100

1.5

Immobilization/surgeryin4wks

1.5

PriorDVT/PE

1.5

Hemoptysis

Activemalignancy

Likelihood
5:likely
04:unlikely

RiskStratification
7:high
26:intermediate
<2:low

WellsScorefor
DVT

Pts

Activecancer

Paralysis,paresis,recentplasterLEcasting

Localizedtendernessalongdeepveinsystem

Entirelegswollen

Calfswelling3cmlargerthanasymptomaticside

Pittingedemaconfinedtosymptomaticleg

Collateralsuperficialveins

PreviouslydocumentedDVT

AlternateDxaslikelyasDVT

Likelihood
2:likely
01:unlikely