Sei sulla pagina 1di 4

VascularDiseases

Ankle­to­BrachialIndex(ABI)

>1.3

Noncompressiblevesselsduetocalcifiedarteries(ex:DM)

0.9­­1.3

Normal

<0.7

Claudication

<0.4

Restpain

RatioofsystolicBPattheankletothesystolicBPatthearm

ArterialDisease

 
 

Occlusiveatherscleroticdiseaseofthelowerextremities

Risks:

 
 

Smoking;diabetes;atherosclerosis

Sites:

 

Superficialfemoralartery(inHunter’scanal) #1

Poplitealartery

Aortoiliacocclusivedisease(Lerichesyndrome)

Sx:

 

Intermittentclaudication

 

○ Calfonlyinsuperficialfemoralandpoplitealarteries

ChronicArterialInsufficiency

○ Buttox,hip,calfinaortoiliacocclusivedisease

(PVD)

 

Diminishedpulses

Smooth/shinyskin;lossofhairandsweatglands

Restpainatnight→hangfootoffbedforrelief

Ischemiculcers→gangrene/necrosis

Dx:

 

ABI<0.9

Tx:

 

STOPsmoking

Cilostazol

Aspirin

Surgery

Pentoxifylline

 

Embolizationofcommonfemoralartery

AcuteArterialOcclusion

Risks:

 

afib;endocarditis;atherosclerosis Sx:(5Ps)

 

○ Pain(acuteonset)

○ Pallor

○ Polar(cold)

○ Paralysis

○ Paresthesias

○ Pulselessness

Dx:

○ Arteriography

Tx:

○ ImmediatelyanticoagulatewithIVheparin

○ Emergentembolectomyviacutdown

○ Fogartyballooncatheter

 

Sx:

○ 5P’sofarterialocclusion

CompartmentSyndrome

Indicationsforemergentfasciotomy:

○ Deltapressure= diastolicbp­­compartmentpressure

○ Deltapressure<30

○ Compartmentpressure>40

VenousDisease

 
 

HistoryofDVT→valvesdestroyedbecomingincompetentcausinggravitational

build­upandalackofpassageoutofsuperficialveinsintodeepveins

Risks:

○ previousDVT

Sx:

○ AmbulatoryvenousHTN

○ Edemarelievedbyelevationoflowerextremity

○ Brawny(brown­black)skinpigmentationfromextravasationofRBCs

ChronicVenous

○ Venousulcersdevelopmediallyabovemedialmalleolus

Insufficiency

○ Skinbecomesthin,atrophic,shiny,cyanotic

○ Achy/tightnessworseatendofthedayandwithsitting/inactivestanding

○ Ulcersarelesspainfulvsarterialinsufficiency

Dx:

○ Clinical

Tx:

○ Legelevation

○ Compressionsocks

○ Unnavenousboot

○ Split­thicknessskingraft

 

Virchow'sTriad:

○ Endothelialinjury

Superficial

○ Venousstasis

Thrombophlebitis

○ Hypercoagulability

 

Locations:

Upperextremities: siteofIVinfusions

Lowerextremities: varicoseveins(greatersaphenousvenoussystem)

Sx:

Painandtenderness

Induration

Erythemaalongthecourseofthevein

Atenderpalpablecord

Dx:

Clinical

Tx:

Mildanalgesic(aspirin)

Bedrestandelevation

Hotcompresses

Monitorforriskofcellulitis

NOanticoagulationneeded(lowriskofPE)

 

Risks:

Virchow’striad

age>60

malignancy

prolongedimmobilization

hypercoagulablestates

majorsurgeryortrauma

cardiacdisease

pregnancy/estrogenuse

Sx:

Usuallyasymptomatic

Lowerextremitypainandswelling(worsewithdependency)

Homan’ssign

Palpablecord

DeepVenous

Dx:

Fever

Thrombosis

DopplerDuplexUS: proximalthrombi(poplitealandfemoral)

Venography: distalthrombi(calf)

Impedanceplethysmography: proximalthrombi

D­Dimertesting: usedtoruleoutDVT

Complications:

○ PE

○ Chronicvenousinsufficiencyin50%ofcases

Phlegmasiaceruleadolens:severelegedemacompromisesarterial

 

supply→impairedsensoryandmotorfunction

Tx:

○ Anticoagulationfor6­12months(goalINR=2­3)

○ Thrombolytictherapy: speedsupresolutionofclotsandisindicatedinPE withhemodynamicinstability

○ ProphylacticIVCFIlter(GreenfieldFilter): ifwarfarincontraindicated

○ Prophylaxisaftersurgery: pneumaticcompressiondevices

ifwarfarincontraindicated ○ Prophylaxisaftersurgery: pneumaticcompressiondevices
ifwarfarincontraindicated ○ Prophylaxisaftersurgery: pneumaticcompressiondevices

WellsScorefor

PE
PE

Pts

Likelihood

 

≥5: likely

   

Clinicalsigns/symptomsofDVT

3

0­4: unlikely

PEmostlikelydx

 

3

 
   

RiskStratification

Tachycardia>100

1.5

≥7: high

   

2­6: intermediate

Immobilization/surgeryin4wks

1.5

<2: low

PriorDVT/PE

1.5

Hemoptysis

1

Activemalignancy

1

WellsScorefor

​DVT
​DVT

Pts

Activecancer

1

Paralysis,paresis,recentplasterLEcasting

1

Localizedtendernessalongdeepveinsystem

1

Entirelegswollen

1

Calfswelling≥3cmlargerthanasymptomaticside

1

Pittingedemaconfinedtosymptomaticleg

1

Collateralsuperficialveins

1

PreviouslydocumentedDVT

1

AlternateDxaslikelyasDVT

–2

Likelihood

≥2: likely

0­1: unlikely

1 PreviouslydocumentedDVT 1 AlternateDxaslikelyasDVT –2 Likelihood ≥2: likely 0­1: unlikely