Identify on this x-ray what is preventing the patient's picc line from being easily removed?

Arrow denotes knot at distal aspect of picc line.  Click image to enlarge.

Removed under fluoroscopy in operating theater by vascular surgery.

Warfarin Failure: What are the treatment options if a patient develops a DVT while on warfarin?

If INR is subtherapeutic, less than 2.0, this is not a true warfarin failure.  Reinstitute heparin or LMWH until INR in target range.

If INR is therapeutic,  consider the following options 

• aim for a higher target INR, 3.0 - 4.0 
• switch to LMWH
• switch to Fondaparinux
• place an IVC filter, although this could serve as a nidus for subsequent thrombosis in the long run

Source

Cleveland Clinic Foundation Intensive Review of Internal Medicine.  2009.

In patients with catheter-associated thrombosis, is routine catheter removal recommended?

No.

Removal is recommended when the catheter is not working, infected or no longer needed, there is a contraindication to anticoagulation, or there are persistent symptoms or signs of DVT despite anticoagulation.


Source

Kucher, N. "Deep-Vein Thrombosis of the Upper Extremities"  NEJM.  3 March 2011.

69 y/o male presents with right groin swelling after recent cardiac cath. Ultrasound notes 1 cm pseudoaneurysm. What are treatment options?

Pseudoaneurysms less than 2 cm can be managed conservatively and monitored with serial imaging to confirm spontaneous resolution.

For larger pseudoaneurysms treatment options include direct ultrasound-guided compression or ultrasound-guided local injection of thrombin or collagen.  However, surgical management is recommended if the pseudoaneurysm is expanding rapidly or causing skin necrosis.


Source

Carrozza, J.  "Complications of diagnostic cardiac catheterization"  Up to Date.  Sept 2010.

What is the cause of this patient's atraumatic, non-cold induced, blue finger?

80 y/o female with history of DM, HTN and CABG presents with acute onset of painless blue finger.  ROS negative. Vitals normal.  Exam pictured above.  EKG sinus.  Labs notable for eosinophilia, new onset renal failure and eosinophiluria (eosinophils in urine).   A test was done and a diagnosis made.  What is it?

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Video of thoracic echo of aorta

Diagnosis: Embolism from mobile aortic plaque.  

Atheroemboli are a potential serious cause of a blue finger.  Clues to diagnosis include atherosclerotic disease risk factors, evidence of acute organ failure secondary to decreased perfusion (ie renal failure, mesenteric ischemia, or stroke), eosinophilia and eosinophiluria.   Transesophageal echo is the diagnostic study of choice because it can detect plaque mobility which cannot be seen on CT or MRI.  Treatment includes secondary prevention of cardiovascular disease (aspirin, statins, BP control, smoking cessation, glycemic control), +/- warfarin/surgery both of which are controversial.

Source

Hirschmann, J. and Raugi, G.  "Blue (or purple) toe syndrome"  J Am Acad Dermatol.  Jan 2009.

Manning, W. and Tunick, P.  "Embolism from aortic plaque: Thromboembolism"  Up to Date.  Feb 2010.

Tunick, P.  "Embolism from aortic plaque: Atheroembolism (cholesterol crystal embolism)"  Up to Date.  Sept 2010.

Image source, blue finger: http://clinicalposters.com/news/2010/20100326_acrocyanosis-raynauds.html

Video source, thoracic echo: http://www.youtube.com/watch?v=1T1Azp0Zk14

True or False. Type A aortic dissection = surgery. Type B = medical treatment.

Semi-false. There are four indications for acute non-medical intervention for Type B aortic dissections.

• aortic rupture
  
• aortic expansion > 5 cm
  
• critical vessel malperfusion
  
• intractable pain

Source

Karmy-Jones, R. et al. "Descending Thoracic Aortic Dissections" Surgical Clinics of North America. 2007.

What is the treatment for phlegmasia cerulea dolens?

Phlegmasia cerulea dolens occurs when there is decreased perfusion to a leg owing to deep venous thrombosis (DVT). This is an uncommon presentation of DVT and is characterized by acute onset of severe nonpitting edema, cyanosis and pain of a lower extremity.


Initial treatment entails heparin +/- thrombolytic therapy, IVC filter and surgical thrombectomy. Consult vascular surgery. Without treatment, gangrene develops over 4-8 days.


Source

Irwin & Rippe's Intensive Care Medicine

Image source: http://www.vein.co.uk/Phlegmasia_caerulea_dolens_001.htm

How can a abdominal aortic aneurysm (AAA) cause hematuria?

This is rare, but here's how hematuria can occur ...

AAA ruptures into the inferior vena cava or one of the iliac veins producing an aortocaval or aortoiliac fistula. This causes hematuria secondary to intravesicular venous hypertension. Patients with this type of fistula may also present with lower extremity edema, high-output congestive heart failure, and a continuous abdominal bruit.


Source

Townsend: Sabiston Textbook of Surgery, 18th ed.

What percentage of patients with biopsy proven temporal arteritis have normal temporal arteries on clinical exam?

33%


Source

Hunder, G. MD. "Clinical manifestations of giant cell (temporal) arteritis" Up to Date. 31 June 2008.

What is the average age of presentation for temporal arteritis?

72 years. The disease essentially never occurs in those < 50.


Source

Hunder, G. MD. "Diagnosis of giant cell arteritis" Up to Date. Jan 2009.

What size thoracic aortic aneurysms should be repaired?

• > 5 - 6 cm for ascending aortic aneurysm
• > 6 - 7 cm for descending aortic aneurysm
  
• > 7 cm in high risk patients
  
• consider repair at smaller size if: presence of symptoms, accelerated growth rate (> 10 mm per year)

Source

Woo, J. MD and Mohler, E MD. "Management and outcome of thoracic aortic aneurysm" Up to Date. 28 Jan 2009.

What size abdominal aortic aneurysms should be repaired?

• > 5.5 cm
  

• consider repair at smaller size if symptomatic and aneurysm > 4 cm, aneurysm is twice the size of the normal segment, aneurysm quickly expanding (> 0.5 cm in diameter in six months)
  

Sources

Powell, J. MD Ph.D., Greenhalgh, R. MD. "Small Abdominal Aortic Aneurysms" N Engl J Med. 2003; 348: 1895-901.

Mohler, E. MD., Fairman, R. MD. "Natural history and management of abdominal aortic aneurysm." Up to Date. 31 July 2008.

What's the difference between neurogenic and vascular claudication?

Both neurogenic and vascular claudication can cause pain in the legs when walking. However, beyond this, these two entities are very different.

Pathophysiology

Neurogenic claudication is caused by lumbar stenosis. Vascular claudication is caused by narrowing of arteries which results in decreased blood flow to the legs.

Symptoms

Pain secondary to neurogenic claudication gets better when bending forward because this position widens the spinal canal (leaning on shopping cart/cane, walking up hill, biking). This position does not improve the symptoms of vascular claudication.

Physical Exam

Neurogenic claudication - neuro exam is often normal but can revel single or multiple lumbosacral radiculopathies. Cauda equina and myelopathy can be rare but serious complications. Vascular claudication - decreased peripheral pulses.

Treatment

Neurogenic claudication - unless symtoms severe, initial treatment is conservative with physical therapy, pain medications, and epidural injections. Spinal surgery can be considered if symtoms do not improve with conservative approach. Vascular claudication - physical therapy, antiplatelet medications and surgery depending on severity.

Sources

Markman, J MD and Gaud, K. BS "Lumbar Spinal stenosis in Older Adults: Curent Understanding and Future Directions." Clinics in Geriatric Medicine. 2008.

Levin, K. MD. "Lumbar spinal stenosis." Up to date. 22 May 2008.

What are risk factors for carotid and vertebral artery dissection?

• heritable connective tissue disorder ie Ehlers-Danlos, Marfan's, autosomal dominant polycystic kidney disease, osteogenesis imperfecta
• family history of arterial dissection
  
• history of minor precipitating trauma ie yoga, painting a ceiling, coughing, vomiting, sneezing, chiropractic manipulation of the neck

Source

Schievink, W. MD. "Spontaneous Dissection of the Carotid and Vertebral Arteries." NEJM. 22 March 2001.

What are the potential complications from a pseudoaneurysm?

• venous compression


• rupture


• hemorrhage


• nerve compression


• compartment syndrome

Levis, Joel MD PhD and Garmel, Gus MD. "Radial Artery Pseudoaneurysm Formation After Cat Bite to the Wrist." Annals of Emergency Medicine. v 51 n 5. May 2008.

What's the treatment of acute limb ischemia?

Acute here is defined as < 2 weeks.

ED treatment is heparin (as arterial emboli or thrombosis is often the cause) and vascular consult.

Definitive treatment of salvagable limb including intra-arterial thrombolytic therapy, angioplasty or surgical revascularization will be based on:

• presumed etiology (embolus vs thrombus)


• location and length of lesion


• duration of symptoms


• availability of autologous vein for bypass grafting


• suitability of the patient for surgery

Source

Mitchell, M. et al "Acute arterial occlusion of the lower extremities." Up to date. May 2008. <http://www.uptodate.com>