Manual of Vascular Medicine

119 Pages·2020·4.14 MB·English

by  Marie Gerhard-Herman, Aaron Aday

Manual of
Vascular Medicine
Marie Gerhard-Herman
Aaron Aday
123
Manual of Vascular Medicine
Marie Gerhard-Herman
Aaron Aday
Manual of Vascular
Medicine
Marie Gerhard-Herman Aaron Aday
Brigham and Women’s Hospital Vanderbilt University
Harvard University Medical Center
Boston Nashville
MA TN
USA USA
ISBN 978-3-030-44714-4 ISBN 978-3-030-44715-1 (eBook)
https://doi.org/10.1007/978-3-030-44715-1
© Springer Nature Switzerland AG 2020
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Vascular Medicine
for All: Introduction
Vascular medicine is an approach in medicine that addresses
concerns about blood vessels anywhere in the body.
Manifestations of compromised blood flow are seen in all
vascular beds.
Abnormalities are seen in vessels of all sizes and locations
including not only the extremities but also the lungs, viscera,
kidneys, and nervous system. The vascular system consists of
a vast number of tubes that leave the heart (pump) and carry
fluid that includes blood cells, hormones, and nutrients via
the arteries and then capillaries to the tissues. Venules and
then veins (85%) and lymphatics (15%) collect and return
the fluid to the heart. Vessels differ by region and function
with pressure and flow for example directing the differentia-
tion of arterial and venous endothelial cells. Embryologic
origin may differ in different regions of a single vessel such as
the aorta. Vascular smooth muscle cells populate the media
and regulate vascular tone. Signals to the media come from
both the endothelial and the adventitial layer.
A unifying approach in the arteries is to recognize that
arterial blood flow is decreased for a finite number of rea-
sons. It is decreased in the setting of fixed changes like dis-
crete blockage or tubular narrowing as well as episodically
decreased with changes like spasm. Clinical manifestations
can range from discomfort to life-threatening emergencies.
Why change in flow has happened involves many possible
etiologies such as atherosclerosis, thrombosis, inflammation,
drugs, or toxins. Venous and lymphatic flow are similarly
impacted by a variety of pathologic states. Given the wide
range of vascular beds and etiologies involved, the care of
vv
vi Vascular Medicine for All: Introduction
patients with vascular disease is fragmented and shared by
many different disciplines. As a result, vascular cases often
present enormous challenges to physicians of all types.
The discipline of vascular medicine tries to address the full
breadth of these diseases and stresses a multidisciplinary
approach to patient care. The majority of vascular medicine
specialists are found in the cardiovascular division of medi-
cine. However, training in the discipline of vascular medicine
has been often cobbled together from many areas without a
clear description of the fundamentals. This has been addressed
by the Core Cardiovascular Training Statement of the
American College of Cardiology, which provides a clear
description of the competencies needed to be able to success-
fully diagnose and treat vascular disease. Vascular medicine
has subsequently been incorporated into board examinations,
and vascular topics are now an integral component of the
cardiovascular examination of the American Board of
Internal Medicine.
The aim of this text is to present essential vascular medi-
cine knowledge that addresses these topics in a straightfor-
ward manner for the practitioner using clinical scenarios,
complete and concise information, and questions allowing for
self-assessment. By providing these key fundamentals in an
approachable format, we hope to improve clinicians’ confi-
dence in diagnosing and treating the full spectrum of vascular
diseases and, ultimately, create a tool to be shared by provid-
ers across all specialties.
Contents
1 Noninvasive Vascular Testing . . . . . . . . . . . . . . . . . . . . 1
References 13
2 Evaluation of Leg Pain . . . . . . . . . . . . . . . . . . . . . . . . . 15
References 19
3 Peripheral Artery Disease . . . . . . . . . . . . . . . . . . . . . . . 21
References 28
4 Aortic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
References 40
5 Renal and Mesenteric Disease . . . . . . . . . . . . . . . . . . . 43
References 49
6 Vasospastic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
References 60
7 Cerebrovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . 63
Clinical Presentation 63
References 70
8 Evaluation of Limb Swelling . . . . . . . . . . . . . . . . . . . . . 73
References 77
9 Venous Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
References 89
10 Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
References 94
vii
viii Contents
11 Vascular Compressive Syndromes . . . . . . . . . . . . . . . . 97
References 102
12 Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
References 111
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113
Chapter 1
Noninvasive Vascular
Testing
Objective Understand what type of testing is most likely to
answer the vascular question.
Vignette A 50 year old female yoga instructor with history of
polymyalgia rheumatica presents with bilateral thigh and calf
ache with exertion that goes away with rest.
Physiologic Testing
Techniques of acquisition in physiological testing include seg-
mental pressure measurements, pulse volume recordings
(PVRs), continuous wave (CW) Doppler, plethysmography,
exercise testing, transcutaneous oximetry, laser Doppler and
skin perfusion pressure. One of the most common tests is the
ankle-brachial index (ABI), which is used to detect peripheral
artery disease (PAD). This test uses sphygmomanometric cuffs,
Doppler instruments, and plethysmographic recording devices
[1]. After the patient rests for 10 minutes in the supine position,
the systolic blood pressure is first measured using a continuous
wave Doppler probe and pneumatic cuff in both brachial arter-
ies at rest. The ankle pressure is then measured in both dorsalis
pedis and posterior tibial arteries above the medial malleo-
© Springer Nature Switzerland AG 2020 1
M. Gerhard-Herman, A. Aday, Manual of Vascular Medicine,
https://doi.org/10.1007/978-3-030-44715-1_1
2 Chapter 1. Noninvasive Vascular Testing
lusafterinflating the cuff to 30 mmHg above the brachial pres-
sure or until the pulse is no longer detectable by Doppler. The
ABIs for each extremity are calculated by dividing each of the
ankle pressures by the higher of the brachial artery pressures
[2]. A normal ABI is between 1.0 and 1.4, whereas an ABI > 0.9
to 1.0 is borderline abnormal. An ABI > 0.90 is considered
diagnostic of PAD. An ABI ≥ 1.4 suggests vessels could not be
reliably compressed which is often due to vascular calcification
artifact and makes interpretation of the pressure measurement
unreliable.
The shape of the arterial waveform is evaluated the same way
throughout the arterial system (Fig. 1.1). Waveforms are obtained
using plethysmography with the cuff inflated to venous occlu-
sive pressure, typically no more than 65 mm Hg. The change in
volume in the limb segment throughout the cardiac cycle causes
a corresponding change in pressure in the cuff. Pulse waveforms
can also be obtained using photoplethysmography, which records
Normal Sharp upstroke
Flat interval between peaks
Possible dicrotic notch
Upstroke
Dicrotic
notch
Mildly abnormal Sharp upstroke
Broadened with no flat
interval between peaks
Wide and broad
peak
Moderately Equal upslope and
abnormal downslope time
Flattened peak
Same angle up
and down slope
Severely abnormal Very low amplitude
Equal upslope and
downslope time Flat,
Flattened peak low amplitude
Figure 1.1 Criteria for normal to abnormal waveform shape