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Vascular Medicine for medical students Zsolt Pécsvárady zspecs@chello.hu Pécs

Vascular Medicine for medical students Zsolt Pécsvárady zspecs@chello.hu Pécs. Basic considerations: ARTERIES: Atherosclerosis is the 1 st major cause of the morbidity and mortality in the western societies. ( 50% or more from all diseases ) Must find as early as possible.

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Vascular Medicine for medical students Zsolt Pécsvárady zspecs@chello.hu Pécs

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  1. Vascular Medicine for medical students Zsolt Pécsvárady zspecs@chello.hu Pécs

  2. Basic considerations: • ARTERIES: • Atherosclerosis is the 1st major cause of the morbidity • and mortality in the western societies. ( 50% or more • from all diseases ) Must find as early as possible. • Atherosclerosis alter the whole vascular system of the • body. The symptoms and signs of the disease • depend on the localisations of the organs involed ( heart, • brain, kidney, GI tract, extremities ), but we have to • check the disease in all locations. • Because of the symmetry of our body, bilateral simultaneous • palpation or auscultation is a great help in the diagnosis. • Nearly 80 % of the diagnosis is available from medical • history and physical examination.

  3. Medical history: symptoms Not enough blood supply - early stages: during activity ( reversible ) - advance stage: end organ failure ( irreversible )

  4. Periferal arterial disease – PAD – Main symptom is intermittant claudication ( IC ) Latin word claudico = to limp 90 % of patients, IC is due to stenosis or occlusion of the arteries supplying the lower extremities Bruit at the place of stenosis ( between 30-70 % stenosis only )

  5. Rose criteria as tool for intermittent claudication1. Do you get pain in either leg on walking?YesNo 2. Does this pain ever begin when you are standing still or sitting?YesNo 3. In what part of your leg do you feel it?Pain includes calf/calvesPain does not include calf/calves ( If calves not mentioned, ask: Anywhere else?) 4. Do you get it if you walk uphill or hurry?YesNoNever hurries or walks uphill 5. Do you get it if you walk at an ordinary pace on the level?YesNo 6. Does the pain ever disappear while you are walking?YesNo 7. What do you do if you get it when you are walking?Stop or slow downCarry on 8. What happens to it if you stand still?RelievedNot relieved 9. How soon?10 min. or lessMore than 10 min.

  6. Sign and symptoms of PAD Exercional leg pain and relief with rest Cool or cold feet to palpation Nocturnal and rest pain relieved with dependency Absent pulses Blanching or pallor on elevation Delay venous filling after elevation Dependent rubor Atrophy of subcutaneous fatty tissue Shiny skin Loss of hair on foot and toes Thickened nails, often with fungal infections Gangrene or nonhealing ulcer

  7. Palpation Auscultation Blood Pressure measurement

  8. Phsysical examination: palpation Pulse: absent = 0 diminished = 1 normal = 2 • Congenital absence of pedal pulses: • 1000 children (age: 1-10 yr ) without PAD: • 12% missing of Art. D.P. • 500 youngsters (age: 0-19 yr) without PAD: • 8.7% missing Art. D.P. • 0.2% misssing Art. T.P. But: Leng & Fowkes, J Clin Epid.1992;45:1101 Ludbrook et al, BMJ, 1962:1:1724

  9. Functional test ( 1 ): Treadmill test to evaluate the claudication distance Standard slope: 12 % Standard speed: 3,2 km/h

  10. Functional test ( 2 ): Ratchow test

  11. Functional tests ( 3 ) : Allen test Pressing radial / ulnar artery and ischemisation

  12. Functional test ( 4 ) : Adson test ( Thoracic Outlet Syndr ) art. radialis art. subclavia

  13. CW Doppler measurement a. D.P.

  14. ABI = Ankle-brachial index BP lower extremities * ABI = -------------------------- BP upper extremities** * The higher between aDP or aTP in one leg ** The higher between the two arms • Normal: 0.91–1.30 • Mild to moderate: 0.70–0.90 • Moderate to severe: 0.40–0.69 • Severe: <0.40 • Non compressable >1.30

  15. Segmental blood pressure measurement w / CW Doppler a. T.P. a. D.P.

  16. Segmental BP measurement

  17. Bi-directionalis Doppler pulse wave analysis

  18. Periferal arterial disease Ed. Coffmann, Eberhardt Humana Press 2003

  19. ABI and mortality rate independent predictor for CV risk 100 ABI >0.85 80 survival (%) ABI 0.40–0.85 60 40 ABI <0.40 20 0 6 4 8 2 10 years McKenna M, et al. Atherosclerosis. 1991;87:119-128.

  20. Duplex ultrasound • 2D presentation – structure of blood vessel wall, IMT, plaque analysis • Doppler measurement • haemodinamique changes • degree of stenosis ( speed of flow) • Indications • stenosis, occlusion, aneurysma, pseudoaneurysma, AV-fistula, controll after operation or PTA ( percutan transluminal angioplasty )

  21. Intima Media Thickness

  22. Angiography Invasive but gold standard

  23. 3D CT,MRInear future

  24. Method Cost Specificity Senzitivity ABI + 95 95 Carotis IMT + 81-100 85-86 EBT +++ 59 89 MRI +++++ 83 100 Comparison of non-invazive screening technics in earlyPAD N.Wong et al 2002 Meta-analysis

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