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Chapter 12 Vascular Diseases

Tan Hong-Yong
Department of Diagnosis
Jining Medical College
Contents:
✦ Aortic Dissection
✦ Primary Arteritis of The Aortic
and Its Main Branches
✦ Peripheral Artery Diseases
✦ Venous Disease
Part 1 Aortic
Dissection
Aortic Anatomy
✦ The aorta is the
main artery that
delivers blood from
the heart to the
body. The aorta
travels through the
chest (thoracic
aorta) and the
abdomen
(abdominal aorta).
Aortic Anatomy
✦ The Aorta is
structurally made up
of three layers:
– Tunica Intima
– Tunica Media
responsible for much
of elasticity and
forms the bulk of the
aortic wall.
– Tunica Adventitia
Overview
✦ Aortic dissection is a tear in
the wall of the aorta that
causes blood to flow between
the layers of the wall of the
aorta and force the layers
apart. Aortic dissection is a
medical emergency and can
quickly lead to death. If the
dissection tears the aorta
completely open (through all
three layers), massive and
rapid blood loss occurs.
Overview
✦ Incidence of aortic dissection is at least
2000 new cases per year
✦ Peak incidence is in the sixth to seventh
decade
✦ Men are affected twice as commonly as
women
✦ Mortality in the first 48 hours is 1% per
hour
– Early diagnosis is essential
Overview
✦ Over 95% of initial tears occur either
in the ascending aorta just distal to
the aorta valve (standford type A) or
just distal to the left subclavian
artery (standford type B).
✦ standford type A: 50% mortality in 48
hours and 90% mortality in 1 month;
✦ standford type B: mortality 10%-20%.
Overview
✦ Involed aorta
branch vessels
showing ischemia:
spinal cord (3%),
visceral (9%),renal
(9%).
Classification
✦ The Stanford system
– Type A 60%
• All dissections involving the
ascending aorta
– Type B 30%
• All other dissections not involving the
ascending aorta
– Ascending aortic dissections are twice
as common as descending
The Stanford system
Clinical Symptoms
✦ Severe, sharp, “Ripping”
“ or “tearing”
posterior chest pain or back pain (occurs
in 74-90% of pts)
– Pain may be associated with syncope,
cerebrovascular accident, MI, or CHF
– Painless dissection relatively
uncommon
✦ Chest pain is more common with Type A
dissections
✦ Back or abdominal pain is more common
with Type B dissections
Physical Exam
✦ Pulse deficit
– Weak or absent carotid, brachial, or femoral
pulses
– these patients have a higher rate of mortality

✦ Acute Aortic Insufficiency


– Diastolic decrescendo murmur
– Best heard along the right sternal border
Other clinical signs
✦ Acute MI
– RCA most commonly involved
– Cardiac tamponade
✦ Pleural effusions
✦ Hypertension or hypotension
✦ Hemothorax
✦ Variation in BP between the arms
(>30mmHg)
✦ Neurologic deficits
– Stroke or decreased consciousness
Other clinical signs
✦ Involvement of the descending aorta
– Splanchnic ischemia
– Renal insufficiency
– Lower extremity ischemia
– Spinal cord ischemia
Diagnostic Tests
✦ EKG
– Absence of EKG changes usually helps
distinguish dissection from angina
– Usually non-specific ST-T wave
changes seen
✦ CXR
✦ Diagnostic Imaging
✦ Cardiac Enzymes
Chest X ray
✦ mediastinal widening(75%)
✦ “calcium sign” -uncommon but highly specific,
>5mm
✦ double-density appearance of the aorta
✦ a localized bulge along a normally smooth
aortic contour
✦ a disparity in the caliber between the
descending and ascending aorta
✦ obliteration of the aortic knob
✦ displacement of the trachea or oesophagus to
the right by the dissection
✦ pleural effusions(left)
Diagnostic Imaging
✦ Not performed until the patient is
medically stable

✦ Spiral CT scan
✦ TEE ----transesophageal
----
echocardiography
✦ MRI----magnetic
MRI---- resonance imaging
✦ Angiography
Spiral CT
✦ Sensitivity 83%
✦ Specificity 90 - 100%
✦ Two distinct lumens with a visible intimal
flap can be identified
✦ Advantages
– Noninvasive
– Readily available at most hospitals on
an emergency basis
– Can differentiate dissection from other
causes of aortic widening (tumor,
periaortic hematoma,etc)
✦ Disadvantages
– Sensitivity lower than TEE and MRI
– Intimal flap is seen < 75% of cases
– Nephrotoxic contrast is required
– Cannot reliably detect AI, or
delineate branch vessels
TEE ---transesophageal
echocardiography
✦ Sensitivity 98% Specificity 95%
✦ Advantages
– Portable procedure
– Yields diagnosis in < 5 minutes
– Useful in patients too unstable for MRI
– True and false lumens can be identified
– Thrombosis, pericardial effusion can be
readily visualized
MRI ---magnetic resonance
imaging
✦ Most accurate noninvasive for evaluating the
thoracic aorta
✦ Sensitivity 98%
✦ Specificity 98%
✦ Advantages
– Safe
– Can visualize the whole extent of the aorta
in multiple planes
– Ability to assess branch vessels, AI, and
pericardial effusion
– No contrast or radiation
✦ Disadvantages
– Not readily available on an
emergency basis
– Time consuming
– Limited applicability in pts with
pacemakers or metallic clips
Angiography
✦ First definitive test for aortic dissection
✦ Traditionally considered “the gold
standard”
✦ Involves injection of contrast media into
the aorta
– Identifies the site of the dissection
– Major branches of the aorta
– Communication site between true &
false lumen
– Can detect thrombus in the false lumen
✦ Disadvantages
– Not very practical in critically ill
patients
– Nephrotoxic contrast
– Risks of an invasive procedure
Differential Diagnosis
– Acute myocardial infarction
• pain is more typically pressurelike but may radiate to
the arms or neck
• pain does not typically migrate over time
• CK-MB levels are elevated
– Pulmonary embolus
• pain is generally respirophasic
• hypoxemia secondary to ventilation/perfusion
mismatch
– Pericarditis
• pain typically changes with position
• auscultation may reveal a pericardial friction rub
• EKG is common diagnostic(ST-segment elevation
prominent in V5-6 and lead I)
Treatment(I)
✦ Emergency methods
– Objective: maintaining systolic blood
pressure between 100 and 120 mmHg
– Antihypertensive agents:
• Sodium nitroprusside: 50-100mg +D5W
500ml infused at a rate of 0.5~3 ug/min
Antihypertensive agents:
✦ Beta-adrenergic blocker: reduce the
heart rate to 60-80/m
– Metoprolol: 5-10 mg IV q 5 min,
– Labetalol: both alpha and beta-
blockade properties
• initial bolus 10-20 mg, then infuse of 1-
2 mg/min
✦Chronic aortic dissection: control of blood
pressure using beta-blocking agents
Treatment(II)
✦ Definite surgical treatment
– Type A: acute aortic dissections require
surgical treatment
– the only contradiction to immediate surgical
repair of a type A dissection is the
simultaneous occurrence of a progressing
stroke
– Type B : medical management mortality is 15-
20%(same as surgery done)
Treatment(II)
✦ Surgery indications: persistent pain,
uncontrolled hypertension, occlusion
of a major arterial trunk, frank aortic
leaking or rupture, or development of
a localized aneurysm.
Long Term Outcome
✦ Type A
– Repaied : Survival at 5 yrs – 68%
– Repaied : Survival at 10 yrs – 52 %
✦ Type B
– 5 yrs 60 - 80%
– 10 yrs 40 – 80%
– Spontaneous healing of dissection is
uncommon.
Part 2 Primary
Arteritis of The Aortic
and Its Main Branches
Summary
✦ Primary arteritis of the aorta and its
branches was known as Takayasu‘s
disease, aortic arch syndrome,
pulseless disease , a rare
polyarteritis of unknown causes. Any
part of the aorta may be affected.
✦ Chronic inflammatory disorder,
affecting the aorta & its major
branches.
✦ Affects women mainly (f:m
= 9:1),
✦ Ages 15 - 25.
Clinical finding
✦ Fever
✦ Myalgias
✦ Arthralgia
✦ pain
✦ Arterial insufficiency:
– Syncope
– Dizziness
– Amaurosis fugax
– Stroke
– Angina
– Pumonary hypertension
– hypertension
Clinical finding
✦ Diagnostic tests
– Angiography
Treatment
✦ Oral corticosteroids..
1 mg/kg daily, with a
maintenance 5 to 10 mg/d.
✦ Cytotoxic drugs in patients
failing steroid treatment.
✦ Surgery and angioplasty:
in advanced disease.
Part 3 Peripheral
artery
diseases
✦ Arteriosclerosis obliteration

✦ Thromboangiitis obliterans

✦ Raynaud's disease and Raynaud's


phenomenon
Section 1 Arteriosclerosis

obliteration
✦ lower extremity atherosclerosis is a
marker for systemic atherosclerotic
disease, involving large and medium
arteries, the iliac, femoral, popliteal,
and/or infrapopliteal arteries
✦ advancing age, male sex
Etiology and pathology
✦ risk factors: hypertension, abnormal
serum lipid levels, cigarette smoking,
impaired glucose tolerance, and
obesity
✦ Pathology: atherosclerotic plaque
Clinical manifestation and
diagnosis
✦ Early stage: intermittent claudication,
Impaired distal pulses, changes of
nutritional dysfunction, the limb is perfused
via collateral pathways
✦ Late stage: rest pain
– Loss of pedal pulses is characteristic of
disease of the distal popliteal artery
✦ general examination: ECG
✦ noninvasive examination: Doppler
✦ arteriography, MRA (Magnetic
resonance angiography),
DSA ( digital subtraction
arteriography )
Differentiation of Arteriosclerosis obliteration
and thromboangiitis Obliterans
Arteriosclerosis Thromboangiitis
obliteration Obliterans

age >45 <45


superficial no common
thrombophlebiti
s
Hypertension, common uncommon
coronary heart
disease
Involving large and the small and
vessels medium medium-sized
arteries arteries and veins

Change of common no
other arteries
Calcification of Can be found no
involving
arteries
arteriography Extensive Segmental
irregular occlusion, others
stenosis and are normal
segmental
occlusion
Treatment
✦ nonoperative treatment
✦ surgical treatment

– percutaneous transluminal
angioplasty
– endarterectomy
– vascular bypass surgery
Section 2 Thromboangiitis
Obliterans
( Buerger Disease )
✦ Thromboangiitis obliterans is a
nonatherosclerotic, segmental, inflammatory,
vasoocclusive disease that affects the small
and medium-sized arteries and veins of the
upper and lower extremities, cyclic upset.
✦ more common in males, aged 20-45 years.
etiology
unclear
✦ external factors: tobacco, cold or
humid weather, chronic trauma,
infection
✦ internal factors: immunologic
dysfunction
✦ exposure to tobacco is essential for
both initiation and progression of the
disease.
Pathology
✦ begin with artery, then vein, from
distal to proximal.
✦ segmental disease
✦ in active stage, nonsuppurtive
inflammation
✦ in end stage, intraluminal thrombosis
progressively organizes, new
capillary formation, vascular fibrosis
✦ ischemic change
Clinical findings
✦ The hands and feet are usually cool.
✦ skin is pale, or cyanosis.
✦ Paresthesias.
✦ pain in limbs, intermittent
claudication
✦ changes of nutritional dysfunction
✦ impaired distal pulses in the
presence of normal proximal pulses.
✦ migratory superficial
thrombophlebitis.
✦ painful ulcerations and/or frank
gangrene of the digits.
General examination
✦ claudication distant and claudication
time
✦ skin temperature
✦ Buerger test
✦ tension relief test
Special examination
✦ Doppler examination
✦ arteriography: formation of distinctive
small-vessel collaterals around areas of
occlusion known as "corkscrew
collaterals"
Clinical stage
✦ First stage: local ischemic stage
✦ Second stage: nutritional ischemic
stage
✦ Third stage: necrotic stage
Thromboangiitis Obliterans
Diagnosis
 Age younger than 45 years, current
(or recent) history of tobacco use
 Presence of distal-extremity ischemia
 History of migratory superficial
thrombophlebitis
 Impaired distal pulses.
 Exclusion of autoimmune diseases,
hypercoagulable states, and diabetes
mellitus by laboratory tests
Treatment
✦ General treatment
– Absolute discontinuation of tobacco
use is the only strategy proven to
prevent the progression of Buerger
disease.
– prevent trauma and thermal or chemical
injury, avoidance of cold environments,
drugs that lead to vasoconstriction
– Buerger exercise
✦ Medication
– Chinese traditional treatment
– vasodilators, antiplatelet drugs,
and anticoagulants
– antibiotics to treat infected ulcers
✦ hypertension oxygen treatment
✦ surgical treatment

to improve distal arterial flow


– lumber sympathectomy
– vascular reconstructive procedures:
bypass transfer, thrombosis
✦ distal limb amputation for
nonhealing ulcers, gangrene
✦ bypass graft
Section 2 Raynaud's disease
and Raynaud's phenomenon
✦ Raynaud's disease and Raynaud's
phenomenon are conditions in which small
arteries (arterioles), usually in the fingers or
toes, constrict more tightly in response to
exposure to cold.
Raynaud’s DZ
✦ Raynaud’s-periodic ✦ Exposure to cold,
constriction of arteries emotional upset,
that supply extremities, tobacco usage.
mostly hands and feet ✦ 3-color changes,
✦ arteriospastic (pulses vasoconstrictive
never absent) spaz-out! pallor-cyanosis-rubor
✦ Freq. Young women or hyperemia
✦ s/s usually precipitated ✦ cold, numbness,
by ✦ pain,tingling,swelling
✦ lasts minutes-hrs.
Raynaud’s disease
✦ Pallor-cyanosis ✦ Ulcers/gangrene &
(especially fingers)- pain may appear at
painful-aching pain- fingertips with
client learns warmth chronicity
relieves pain-go inside
warm, or placed in warm
✦ TX-prevent chilling,
water-which relieves avoid risk factors, no
vasopsasms-blood ETOH,tobacco, wear
rushes to the extremity gloves, heat,
vasodilators, avoid
stress
Part 4 Introduction of
venous diseases
✦ deep veins, include the anterior tibial,
posterior tibial, peroneal, popliteal, deep
femoral, superficial femoral, and iliac
veins.
✦ superficial veins, include the lesser and
greater saphenous veins and their
tributaries. These include the lateral and
medial femoral cutaneous branches, the
external circumflex iliac vein, the
superficial epigastric vein, and the internal
pudendal vein
DEEP VENOUS
THROMBOSIS
✦ Deep vein thrombosis is the
formation of a blood clot in one
of the deep veins of the body,
usually in the leg
✦ DVT ususally originates in the lower
extremity venous level ,starting at the calf
vein level and progressing proximally to
involve popliteal ,femoral ,or iliac system.
80 -90 % pulmonary emboli originates here .
Presentation and Physical
Examination
✦ Calf pain or tenderness, or both
✦ Swelling with pitting edema
✦ Swelling below knee in distal deep vein
thrombosis and up to groin in proximal
deep vein thrombosis
✦ Increased skin temperature
✦ Superficial venous dilatation
✦ Cyanosis can occur with severe
obstruction
✦ Palpate distal pulses and evaluate
capillary refill to assess limb perfusion.
✦ Move and palpate all joints to detect acute
arthritis or other joint pathology.
✦ Neurologic evaluation may detect nerve
root irritation; sensory, motor, and reflex
deficits should be noted
✦ Homans'’ sign: pain in the posterior calf or
knee with forced dorsiflexion of the foot
✦ Search for stigmata of PE such as
tachycardia (common), tachypnea or
chest findings (rare), and
✦ exam for signs suggestive of
underlying predisposing factors.
DVT
Diagnostic Studies
✦ Clinical examination alone is able to confirm
only 20-30% of cases of DVT
✦ Blood Tests
✦ the D-dimer
✦ INR.
✦ Current D-dimer assays have predictive
value for DVT, and the INR is useful for
guiding the management of patients with
known DVT who are on warfarin (Coumadin)
D-dimer
✦ D-dimer is a specific degradation product
of cross-linked fibrin. Because concurrent
production and breakdown of clot
characterize thrombosis, patients with
thromboembolic disease have elevated
levels of D-dimer
✦ False-positive D-dimers occur in patients
with
– recent (within 10 days) surgery or
trauma,
– recent myocardial infarction or stroke,
– acute infection,
– disseminated intravascular coagulation,
– pregnancy or recent delivery,
– active collagen vascular disease, or
metastatic cancer
Imaging Studies
✦ Invasive
 venography,
radiolabeled fibrinogen
✦ noninvasive
ultrasound,
plethysmography,
MRI techniques
venography
Treatment
✦ Anticoagulation
✦ Thrombolytic therapy for DVT
✦ Surgery for DVT
✦ Filters for DVT
✦ Compression stockings
Anticoagulation
✦ Heparin prevents extension of the
thrombus
✦ Heparin's anticoagulant effect is related
directly to its activation of antithrombin III.
Antithrombin III, the body's primary
anticoagulant, inactivates thrombin and
inhibits the activity of activated factor X in
the coagulation process.
At the present time, 3 LMWH preparations
✦ Enoxaparin,
✦ Dalteparin,
✦ Ardeparin
warfarin
✦ Interferes with hepatic synthesis of
vitamin K-dependent coagulation factors
✦ Dose must be individualized and adjusted
to maintain INR between 2-3
✦ 2-10 mg/d PO
✦ caution in active tuberculosis or diabetes;
patients with protein C or S deficiency are
at risk of developing skin necrosis
Surgery for DVT
✦ indications
– when anticoagulant therapy is ineffective
– unsafe,
– contraindicated.
– The major surgical procedures for DVT
are clot removal and partial interruption
of the inferior vena cava to prevent
pulmonary embolism.
This patient underwent a thrombectomy. The thrombus
has been laid over the approximate location in the leg
veins where it developed.
Complications
✦ Acute pulmonary embolism
✦ Hemorrhagic complications
✦ Chronic venous insufficiency