vascular physiology 3 upper and lower extremity arterial conditions other than atherosclerosis
TRANSCRIPT
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Vascular Physiology 3
• Upper and lower extremity arterial conditions other than atherosclerosis.
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Upper extremity ischemia
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Emboli
• Heart most likely source of non-atherosclerotic emboli. 10-20% of all cardiac emboli lodge in upper extremity. 70% of all upper ext emboli come from heart. – Thrombus
– Tumor
– Valvular lesions
– Fairly common
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Raynaud’s Disease(Cold sensitivity)
• Female- most frequent 18-30 years• Abnormal vasoconstriction of extremities
upon exposure to cold or emotional stress. • Intermittent attacks of pallor, cyanosis,then
rubor of digits (usually upper), bilateral or symetrical, normal radial and ulnar pulse.
• No evidence of obstructive disease.• Fairly common
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Raynaud’s Disease cont.
• Treatment– Warmth, gloves, socks, avoid cold– Vasodilators
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Raynaud’s Phenomenon(cold sensitivity)
• Intermittent pallor, cyanosis, redness,normal. Repeats.
• Response to cold or emotion.• Numbness, tingling, burning may occur.• Secondary to such conditions as occlusive arterial
disease, systemic scleroderma, thoracic outlet syndrome, pulmonary hypertension, myxedema or trauma.
• Fairly common
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Raynaud’s Phenomenon cont.
• Vascular Lab to look for underlying cause of vasoconstriction.
• Vascular Lab to document vasospasm.
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Arterial/Venous fistulae
• Surgically constructed for hemodialysis– Cimino-Brescia: end to end or side to side anastomosis
between the radial artery and cephalic vein at wrist.
– Prosthetic graft (PTFE) • Loop between brachial art and antecubital vein
• Straight between radial art at wrist and antecubital vein
• Straight between brachial artery and subclavian vein
• Common
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Buerger’s Disease
• Thromboangiitis Obliterans (fairly uncommon) – Men <40yrs– 99% smoke– Affects small and medium arteries, can affect
veins also.– Inflammation leading to formation of thrombi– Tissue necrosis develops early because of poor
collaterals in end arteries of fingers and toes.
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Trauma
• Dissection, thrombosing, Arterial/venous fistulae.
• Acute ischemia
• Can happen to upper or lower ext.
• Fairly common
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Thoracic Outlet Syndrome
• Compression of nerve, artery, or vein in the thoracic outlet area.
• Area of 1st rib, clavicle, and scalene muscle.
• A “cervical rib” with or without a fibrous band may be present.
• Uncommon
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Types of Thoracic Outlet Syndrome.
True neurogenic: Wasting of muscles of hand and hand weakness, with positive electromyography.
Vascular Thoracic Outlet: an arterial or venous lesion is present on angiography.
Duplex and photocell exam is helpful and most likely ordered before angio.
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Thoracic Outlet Types cont.
• Disputed Thoracic Outlet.– Weakness, parathesia, pain of hand, arm,
shoulder girdle, chest wall, and headache. – Eletromyographic test normal. – Hand wasting is never found. – Patients do not progress to true neurogenic or
vascular thoracic outlet.
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Tumor
• Muscular masses can be present in the upper extremity. Some are vascular and cause bruit.
• Masses can compress artery or vein.
• Uncommon
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Rheumatic/Autoimmune Diseases
Giant Cell Arteritis: Temporal arteritis and Takayasu’s
Can cause arm claudication or Raynaud’s phenomenon. Uncommon
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Radiation arteritis
• Inflammation of subclavian and axillary arteries resulting from radiation treatment.
• Uncommon but is seen
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Fibromuscular dysplasia
• Systemic disorder, smooth muscle hyperplasia, and general disorganization of the arterial wall.
• Can cause arm claudication. Uncommon
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Summary upper
• Common causes for upper art conditions– Emboli– Cold sensitivity (vasospasm in Raynaud’s)– A-v grafts
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Upper summary cont.
• Somewhat common – Buerger’s Disease (men more than women)– Trauma
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Upper summary cont.
• Uncommon upper ischemia causes – Thoracic outlet– Tumor – Rheumatic/Autoimmune disease – Radiation arteritis– Fibromuscular dysplasia
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Non-atherosclerotic Lower Extremity arterial conditions
• Account for much less lower extremity ischemia than upper extremity ischemia.
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Emboli
• Causes acute ischemia/ medical emergency• Most non-atherosclerotic emboli come from
the heart• Entire lower extremity can be involved,
most occlude lower leg, foot or toes. • Heparin, thrombolytic therapy,
embolectomy• Common
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Pseudoaneurysm
• Mostly traumatic
• Infection is most serious complication
• Can be painful
• Rarely causes ischemia
• Occurs more in lower extremity than upper
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Popliteal Artery entrapment
• Popliteal artery compression by medial head of gastrocnemius muscle.
• Young patients
• With exercise the gastrocnemius muscle contraction compresses artery.
• Uncommon
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Trauma
• Dissection, thrombosing, Arterial/venous fistulae.
• Acute ischemia
• Can happen to upper or lower ext.
• Fairly common
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Arterial-Venous Fistulas
• Can be surgically created in lower ext for hemodyalisis. Occurs less frequently than in upper. Complications: aneurysm, pseudoaneurysm, infection, graft occlusion.
• Fairly common (more often in arms) • Traumatic:
– Artery and venous connection due to trauma– Infection is most serious complication over ischemia– Can be painful
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Raynaud’s Disease
• Affects upper extremities more significantly than lower.
• Vasospasm without underlying occlusive or systemic cause.
• Uncommon in lower
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Arteritis
• All types of arteritis affects upper extremities much more frequently than lower. (Takayasu’s, Giant Cell Arteritis, Polyarteritis or periarteritis.
• Uncommon to see these listed as cause for lower extremity ischemia, but is possible.
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Buerger’s Disease
• Thromboangiitis Obliterans: described as rarely a cause, and accounting for less than 1% of lower extremity vascular disease.
• Young, male, smokers, digit ischemia• Sudden onset• Claudication of foot and arch rather than legs.• Associated superficial thrombophlebitis • Less likely to cause lower ext ischemia than upper
extremity ischemia.
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Advential Cyst
• Cyst of advential layer of arterial wall, causing stenosis or occlusion by thrombosing.
• Can cause claudication
• Can be surgically drained or bypassed.
• Can reoccur
• Uncommon
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Hypercoagulability
• Heparin induced thrombosis
• Antithrombin III deficiency
• Abnormal fibrinolytic system
• Abnormal platelet aggregation
• Uncommon
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Hematologic disease
• Polycythemia Vera
• Thrombocytosis
• Dysproteinemias.
• Sudden onset, usually affects digits
• Hematology consult for therapy
• Uncommon
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Summary of Lower extremity arterial complications
• Common – Emboli– Pseudoaneurysm (Lower ext arterial injury,
does not usually cause ischemia)
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Summary lower cont.
• Fairly common – Popliteal artery entrapment – Trauma– Arterial – venous fistula
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Summary Lower ext arterial
• Uncommon in Lower ext ischemia– Raynaud’s disease or phenomena– Arteritis– Buerger’S Disease – Advential cyst – Hypercoagulability – Hematologic disease
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References Vas Phy 3
• Slides 1,2,3,4,5 Taber’s cyclopedic Medical Dictionary, Davis 1985
• Slide 5 Intro to Vascular Ultrasonography, Zwiebel, Saunders, 2000, Pg258
• Slides 6,7,8 Intro to Vascular Ultrasonography, Zwieber, pgs 259-260. & Handbook of Patient Care in Vascular Disease, 4th Ed., Hallett, Brewster, Rasmussen pgs 238-247
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References Vas Phy 3 cont
• Slide 9 Intro to Vascular Ultrasonography, Zwiebel, 2000, pg 259. & Cardiology Clinics, PVD in The Elderly, Breslin Ed., August 1991, pgs 559-560.
• Slides 10,11 Intro to Vascular Ultrasonography, Zwiebel, 2000, pgs 259-261. & Vascular Diagnosis 4th Ed, Bernstein, Mosby, 1993.
• Slide 12 Vascular Diagnosis 4th Ed., Bernstein, Mosby, 1993 pg 631
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Refer Vas Phy 3 cont.
• Slides 13,14,15 Cardiology Clinics, August 1991 pgs547-552. & Vascular Diagnosis, Bernstein, pg 631
• Slides 16,17 Intro to Vascular Ultrasonography, Zweibel, 2000 Pg 260.
• Slide 20 Handbook of Patient Care in Vascular Disease 4th, Hallett, pg37.
• Slide 21 Cardiology Clinics, August 1991,pgs 501
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Reference Vas Phy 3 cont.
• Slide 22 Intro to Vascular Ultrasonography, Zweibel, 2000, pg205. & Cardiology Clinics, August 1991 pgs 559-560
• Slide 23,26 Cardiology Clinics, August 1991, pg501.
• Slide 27 Cardiology Clinics, August 1991, pgs 501-502/
• Slide 29 Cardiology Clinics, August 1991, 497-513.