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Questions and Answers

What is the initiating event that leads to early atherosclerotic disease?

  • High blood pressure
  • Inflammatory response
  • Increased HDL levels
  • Endothelial injury (correct)

    • The fatty streak is characterized by the accumulation of foam cells.

    True

    What role do macrophages play in the progression of atherosclerosis?

    They secrete growth factors and scavenge cholesterol.

    In advanced atherosclerosis, an atheroma is characterized by a mass of extracellular cholesterol and _____ cells.

    <p>foam</p> Signup and view all the answers

    Match the following terms with their definitions:

    <p>Takayasu's Arteritis = Affects large vessels, causing inflammation. Giant Cell Arteritis = Characterized by headache and jaw claudication. Pseudoaneurysms = A false aneurysm formed by a breach in the vessel wall. True Aneurysms = Involves all layers of the vessel wall.</p> Signup and view all the answers

    Which type of plaque is most likely to ulcerate and embolize?

    <p>Fatty plaque</p> Signup and view all the answers

    Neovasculature plays a role in supplying plaque with necessary nutrients and immune cells.

    <p>True</p> Signup and view all the answers

    What is the significance of smooth muscle cell migration in atherosclerosis?

    <p>It contributes to plaque formation and stabilization.</p> Signup and view all the answers

    Which of the following is a common location for atherosclerotic plaques to form?

    <p>Carotid bifurcation</p> Signup and view all the answers

    Intermittent claudication occurs during rest.

    <p>False</p> Signup and view all the answers

    What is the primary cause behind ischemic rest pain?

    <p>Severe ischemia and sensory nerve damage</p> Signup and view all the answers

    Atherosclerosis leads to the formation of ___ which can cause blockage in blood vessels.

    <p>plaques</p> Signup and view all the answers

    Match the following terms with their definitions:

    <p>Intermittent Claudication = Pain caused by insufficient blood flow during exercise Ischemic Rest Pain = Persistent pain occurring at rest, usually at night Gangrene = Necrosis of tissue with a foul smell Elevation pallor = Color change when the limb is raised</p> Signup and view all the answers

    What is a characteristic finding in patients with occlusive disease?

    <p>Diminished or absent arterial pulsations</p> Signup and view all the answers

    Calcification of plaques is a common feature in advanced atherosclerosis.

    <p>True</p> Signup and view all the answers

    Which stage of lower extremity atherosclerosis involves significant decrease in ankle pressure during and after exercise?

    <p>Stage 2</p> Signup and view all the answers

    Ischemic pain typically occurs in ___ muscle groups and is relieved by stopping exercise.

    <p>functional</p> Signup and view all the answers

    What occurs when atherosclerotic plaque ruptures?

    <p>Thrombus formation</p> Signup and view all the answers

    What is the typical age of onset for Takayasu's Arteritis?

    <p>15-30 years</p> Signup and view all the answers

    The dissection in a dissecting aneurysm separates the layers of the arterial wall by a column of blood.

    <p>True</p> Signup and view all the answers

    What is the condition known as Giant Cell Arteritis primarily affecting?

    <p>The arterial wall, particularly affecting the thoracic aorta and carotid arteries.</p> Signup and view all the answers

    A _______________ is characterized by a rupture in the wall of the artery resulting in a loss of blood.

    <p>pseudoaneurysm</p> Signup and view all the answers

    Match each type of aneurysm with its description:

    <p>Fusiform Aneurysm = Circumferential dilation of an artery wall Saccular Aneurysm = Outpouching on one side of the artery wall Pseudoaneurysm = Rupture resulting in blood loss outside the artery True Aneurysm = Defect in the tunic media with intact wall</p> Signup and view all the answers

    Which of the following is NOT a clinical manifestation of Giant Cell Arteritis?

    <p>Cold sensitivity in extremities</p> Signup and view all the answers

    What is the main risk factor associated with Thromboangiitis Obliterans?

    <p>Smoking</p> Signup and view all the answers

    True aneurysms typically occur in the abdominal aorta, thoracic aorta, and popliteal artery.

    <p>True</p> Signup and view all the answers

    In Takayasu’s Arteritis, the symptoms related to stenosis may include ________________.

    <p>claudication</p> Signup and view all the answers

    Match the symptom with its corresponding disorder:

    <p>Headaches = Giant Cell Arteritis Pulslessness = Takayasu’s Arteritis Acute severe pain = Thromboangiitis Obliterans Color changes in fingers = Raynaud’s Syndrome</p> Signup and view all the answers

    Which of the following is a common complication of an aneurysm?

    <p>Thrombus formation</p> Signup and view all the answers

    What are the 'six P's' commonly associated with acute arterial disease?

    <p>Pain, Paralysis, Paresthesia, Pallor, Pulselessness, Poikilothermia</p> Signup and view all the answers

    A saccular aneurysm remains connected to the arterial lumen.

    <p>True</p> Signup and view all the answers

    The inflammation in Giant Cell Arteritis primarily affects the __________ layer of arteries.

    <p>intimal</p> Signup and view all the answers

    Study Notes

    Flow

    • Normal flow is 151 ml/min
    • Post exercise flow is 734 ml/min

    Acute Arterial Disease

    • Sudden cessation of blood flow to an extremity

    • Causes:

      • Intrinsic obstruction
        • Formation of a thrombus
        • Impaction of a thrombotic embolus
        • Impaction of an atheromatous embolus
        • Catheter induced thrombus
      • Extrinsic obstruction
        • Blunt or penetrating injury
        • Intimal tear or dissection
        • Proximity injury
        • Compression by a neoplastic mass
        • Venous outflow blockage

    • If collateral circulation isn't well developed, acute ischemia will occur

    • Muscle necrosis may occur within 4 to 6 hours

    • Key symptoms:

      • Pain
      • Paralysis
      • Paresthesia
      • Pallor
      • Pulselessness
      • Poikilothermia

      Aneurysmal Disease

    • Abnormal dilation of an artery wall

    • Causes:

      • Complication of atherosclerosis
      • Congenital defects
      • Infection (syphilis)
      • Trauma
      • Iatrogenic (caused by medical procedure)

    True Aneurysm

    • Develops due to a defect in the tunic media of the artery wall
      • The artery wall dilates but remains intact
    • Two types:
      • Fusiform Aneurysm
        • Circumferential dilation where the wall balloons on all sides
        • More commonly associated with atherosclerosis
      • Saccular Aneurysm
        • Sac-like out pouching on one side of the arterial wall
        • Remains connected to the arterial lumen
        • More associated with infection or congenital development

    False Aneurysm (Pseudoaneurysm)

    • A rupture in the artery wall
    • Results in blood loss from the artery
    • Blood flows out of the wound and clots in the tissues
    • The wall of the aneurysm is thrombus

    Common Sites

    • True aneurysms are commonly found:
      • Abdominal aorta (below level of the renal arteries)
      • Thoracic aorta
      • Popliteal artery

    Clinical Manifestations

    • Often asymptomatic
    • Often detected during a vascular exam as a palpable, pulsatile mass
    • Rupture of the aneurysm is often catastrophic
    • The aneurysm is a site for thrombus formation
      • The thrombus can be the source of thromboemboli

    Thrombo-emboli

    • Blue toe syndrome

    Dissection (Dissecting Aneurysm)

    • Separation of the layers of the arterial wall by a column of blood
    • Creates a false arterial lumen which communicates with the true lumen via a tear in the intima
    • The dissection usually extends along one side of the artery
    • Dissection can partially or totally occlude any vessel in the path of the dissection by separating the vessel orifice from the true lumen

    Arteritis

    • Inflammation and damage to arterial walls
    • Common types:
      • Giant cell (temporal)arteritis
      • Takayasu’s arteritis
      • Thromboangiitis obliterans (Buerger’s Disease)
      • Polyarteritis nodosa
      • Kawasaki Disease

    Giant Cell Arteritis (Temporal Arteritis)

    • Inflammation of the arterial wall affecting the thoracic aorta, large branches of the aorta and extracranial branches of the carotid arteries
    • The intimal layer is thickened, with concentric narrowing and occlusion of the lumen
    • May be localized, multifocal or widespread

    Giant Cell Arteritis (Temporal Arteritis)

    • Women are more affected than men
    • Mean age of onset is 70 years
    • About 40 – 60% of patients have polymyalgia rheumatica
    • Key symptoms:
      • Headaches
      • Visual disturbances
      • Temporal artery tenderness
      • Pain in jaw muscles
      • Fever, weight loss, malaise
      • Fatigue
      • ESR and C-reactive protein are elevated

    Takayasu’s Arteritis

    • Inflammatory disease affecting the aorta, it's branches and pulmonary arteries
    • Etiology/cause is unknown; may be related to immune response
    • May cause arterial stenosis, occlusion, or aneurysms
    • Rare disease
      • More common in women and Asians
      • Young onset (15 – 30 years)

    Takayasu’s Arteritis

    • Key symptoms:
      • Systemic phase
        • Fever, fatigue, weight loss
        • Non-specific aches and pains
        • Tenderness over affected vessels
        • Elevated ESR
      • Occlusive phase
        • Claudication
        • Stroke symptoms
        • Pulselessness
        • Bruits

    Thromboangiitis Obliterans (Buerger’s Disease)

    • Inflammatory condition affecting small and medium sized arteries of upper and lower extremity
    • Produces varying degrees of obstruction
    • Inflammation is often accompanied by thrombosis, fibrosis and scarring
    • More common in men, ages 20 – 40
    • Almost always associated with smoking
    • More common in Asian rather than Western countries

    Thromboangiitis Obliterans (Buerger’s Disease)

    • Key symptoms:
      • Hands or feet may be pale, red or bluish
      • Hands or feet may be cold
      • Pain in the hands and feet
        • Acute, severe
        • Burning or tingling
        • Often occurring at rest
      • Intermittent claudication
      • Skin changes or ulcers on hands or feet

    Arteriospastic Disorders

    • Raynaud’s Syndrome
    • Acrocyanosis
    • Livedo reticularis
    • Cold hypersensitivity

    Raynaud’s Syndrome

    • An episode of constriction of small arteries or arterioles in the extremities resulting in characteristic color changes in the digits (usually fingers)
    • This occurs in response to exposure to cold or emotional stress
    • Attacks are usually completed in 30 to 60 minutes but may last until the person rewarms hands

    Raynaud’s Syndrome

    • Color changes
      • Pallor
      • Cyanosis
      • Rubor

    Raynaud’s Syndrome

    • Epidemiology
      • Up to 30% of women and 25% of men report a history of Raynaud’s type symptoms
      • 70% of persons seeking treatment are women
      • Incidence is higher in cold environments
      • Occupational incidence
        • Pneumatic drill (jack hammer) operators
        • Cold storage and workers

    Raynaud’s Syndrome

    • Pathophysiology
      • Obstructive Raynaud’s (Secondary Raynaud’s; Raynaud’s Phenomenon)
        • Pre-existing arterial occlusive disease in palmar and/or digital arteries
        • The greater the amount of occlusion, the more pronounced the incidence of Raynaud’s
      • Vasospastic Raynaud’s (Primary Raynaud’s; Raynaud’s Disease)
        • Normal blood flow in digits at room temperature
        • Heightened physiological response to cold exposure
        • Idiopathic

    Raynaud’s Syndrome

    • Clinical Manifestations
      • Mild pain
      • Numbness
      • Ischemic digital ulceration in obstructive Raynaud’s

    Early Atherosclerotic disease

    • Endothelial injury
      • Initiating event
      • Attract and activate macrophages
    • Deposition of LDL into intima
    • Recruitment of lymphocytes, monocytes

    Initial Injury

    • Causes alteration in metabolism of endothelial cells
      • Increased permeability
      • Secretion of procoagulants
      • Stimulation of endothelial cell reproduction
      • Secretion of vasoactive substances and growth factors

    Early Atherosclerotic Disease

    • Role of endothelial cells
      • Secrete growth factors
      • Secrete vasoactive agents
    • Role of platelets
      • Secrete growth factors
      • Adhesion-aggregation reaction
      • Secrete vasoactive agents

    Inflammatory process

    • Monocytes in intima become macrophages
    • Role of macrophages
      • Secrete growth factors
      • Scavenge cholesterol
    • Growth factors attract smooth muscle cells and cause them to proliferate
    • Macrophages penetrate endothelium and accumulate lipids, become foam cells
    • “Fatty streak” appears

    Fatty Streak

    • Earliest manifestation, often seen in children
    • Characterized by the accumulation of foam cells
    • Lesions are flat or slightly raised “yellow” streaks oriented in the direction of flow
    • Nonobstructive and subclinical

    Atheroma Thickening

    • Migration/proliferation of smooth muscle cells from media
    • Neovasculature supplies plaque
    • Fibrous Plaque
      • Myointimal cells
        • Proliferate
        • Secrete matrix
        • Form fibrous cap
      • Loss of endothelium

    Atheroma

    • Characteristic of more advanced disease
    • A mass of extracellular cholesterol and foam cells surrounded by a fibrous connective tissue cap
      • Fatty plaque
        • Soft, lipid rich pool of extracellular cholesterol
        • Most likely to ulcerate and embolize
      • Fibrofatty plaque
        • Solid, composed mainly of collagen and smooth muscle

    Advanced Atherosclerosis

    • Central core of macrophage foam cells
    • Extracellular lipid deposits
    • Cell necrosis
    • Scar tissue formation (fibrosis)
    • Macrophage lysis
    • Intraplaque hemorrhage
    • Rupture of fibrous cap
    • Plaque ulceration
    • Thrombus formation
    • Embolization
    • Calcification
    • Proportion of LDL/HDL increases 5:1
    • Monocyte migration into subendothelial space

    Atherosclerosis

    • Development
    • While atherosclerosis is a diffuse disease, plaques typically are focal
    • Common locations are bifurcations and branch points
      • Carotid bifurcation (carotid bulb/proximal ICA)
      • Aortic bifurcation into CIA’s
      • Distal SFA (in adductor canal)
        • Most common site of atherosclerotic develop in the LE’s
      • Common femoral bifurcation into SFA, PFA
      • UE’s – Subclavian artery origin

    Clinical Aspects of Peripheral Arterial Disease

    • Pathophysiology
      • When a large artery is obstructed, blood flow into and blood pressure in smaller arteries is reduced
      • If oxygen demand of tissues exceeds the ability of arteries to supply oxygenated blood, ischemia results
      • An approximately 50% reduction in vessel diameter is required before there is clinically significant reduction in blood flow
      • Amount of ischemia depends upon extent of collateral blood supply

    Clinical Aspects of Peripheral Arterial Disease

    • Intermittent Claudication
      • AKA: Functional limb ischemia
      • Pain that occurs after a certain amount of exercise and is relieved by rest
        • Blood flow is normal in resting limb but cannot be increased in response to exercise
        • Pain is always experienced in a functional muscle group
        • It is reproducibly precipitated by a consistent amount of exercise
        • It is promptly relieved by stopping the exercise

    Clinical Aspects of Peripheral Arterial Disease

    • Ischemic Rest Pain
      • Persistent, severe ache or gnawing pain
      • Often occurs at night and persists for hours at a time
      • First occurs when the foot is elevated; usually localized in digits/foot
      • Can often be relieved by dangling foot or walking
      • This condition implies that blood flow to the foot is below that necessary to meet normal metabolism
        • Severe ischemia and sensory nerve damage
      • If left untreated, it generally leads to tissue necrosis (gangrene)

    Clinical Aspects of Peripheral Arterial Disease

    • Pain of ischemic neuropathy
      • Occurs late in the course of the disease
      • Pain is associated with the distribution of sensory nerve fibers in the extremity

    Clinical Aspects of Peripheral Arterial Disease

    • Coldness and cold sensitivity
      • Persons with occlusive disease often complain of coolness in the extremities
      • The foot may be cold to touch
      • More sensitive to exposure to cold

    Clinical Aspects of Peripheral Arterial Disease

    • Impaired arterial pulsations
      • Diminished or even loss of palpable pulse is a common finding in occlusive disease
      • Particularly in the foot

    Clinical Aspects of Peripheral Arterial Disease

    • Color changes
      • The ischemic extremity is often pale or cyanotic, particularly when elevated (elevation pallor)
      • Color may return when extremity is lowered (dependent rubor)

    Clinical Aspects of Peripheral Arterial Disease

    • Ulceration and gangrene
      • Lesions may occur spontaneously or be induced by trauma
      • Ulcers develop on tips of digits and between toes
      • Secondary infections can lead to abscess formation and gangrene in the extremity
        • Gangrene is a black, foul-smelling area of necrotic tissue, adjacent to living tissue

    Clinical Aspects of Peripheral Arterial Disease

    • Skin changes
      • Thickened and deformed nails
      • Loss of hair on extremity

    Classification of Lower Extremity Atherosclerosis

    • Stage 1
      • Pathological changes in arteries
      • Patient asymptomatic
      • May have decreased pedal pulses
      • With exercise – mild decrease in ankle pressure
    • Stage 2
      • Intermittent claudication
      • Asymptomatic at rest
      • Intermittent claudication
      • Significant decrease in ankle pressure during and following exercise.

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