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 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of transla- tion, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimi- lar methodology now known or hereafter developed. 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This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland 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