Hypertension and arterial aneurysm.

The rather common coexistence of arterial aneurysm and systemic hypertension may be attributed to their respective frequency as clinical findings. The development of hypertension secondary to renal ischemia that can occur as a complication of certain types of aneurysmal disease is well recognized. Less well appreciated is the evidence to implicate hypertension as a factor in the pathogenesis of arterial aneurysms, perhaps in their progressive enlargement, and even in rupture. Furthermore, after resection of an aneurysm, systemic hypertension adversely influences survival, and it is an important contributing factor in the development of false aneurysms. A relation between hypertension and aortic dissection has received more recognition. Just how systemic hypertension contributes to the occurrence of aortic dissection is not clear, but the effective control of hypertension has the potential for decreasing the incidence of aortic dissection. The curious clinical association of hypertension with the location of the primary tear in the proximal part of the descending aorta (type III or type B) has several plausible explanations.

Recommendations for training in vascular medicine. American College of Cardiology Peripheral Vascular Disease Committee.

Each trainee in vascular medicine must be eligible for the board certification examination of the American Board of Internal Medicine or its equivalent. Training faculty, preferably at least two members, should meet the qualifications and training requirements described in this report. They must be dedicated, effective teachers and should spend most of their time in research, education and patient care related to peripheral vascular diseases. A curriculum of training should be established. Faculty experts in related specialties and in the related basic sciences should be available for teaching. The institution should have a fully equipped noninvasive vascular laboratory and areas where catheter revascularization techniques and vascular surgery are performed. The period of training should not be less than 1 year, preferably continuous.

Participation by internists in primary care; Results of a survey of Mayo clinical alumni.

In late 1972, a survey of Mayo Graduate School alumni was undertaken to determine if changes were needed to make the internal medicine residency program more relevant to such medical practice in the 1970s. Responses were obtained from 783 of the 1,109 former residents in internal medicine to whom questionnaries were sent. Althought nearly half of the responders indicated a subspecialty component to their practice,73% indicated they spend more than half of their time in the delivery of parimary car; and additional 15% reported that primary care occupied from 20% to 50% of their professional time. There was agreement that more general internists are needed and that better geographic distribution of physicians would improve health care delivery.

Chest pain in a young woman.

Chest pain in a young person is often caused by chest wall tenderness, associated with mitral valve prolapse, or attributed to psychologic factors. Ischemic cardiac pain may be overlooked because of its rare occurrence in this age group. A 35-year-old woman complained of substernal chest pressure precipitated by exertion and relieved by rest. The symptom had been noted for 15 years. Worsening of the symptom during dancing prompted her to seek medical advice. She had no other illnesses, was taking no medications, was a nonsmoker, and had no family history of coronary disease. Physical examination disclosed a grade 1 (on the basis of 1 to 6) systolic ejection murmur, an ejection click, and a grade 2 diastolic murmur. An exercise test produced symptoms at 4 minutes. Coronary arteriography showed the absence of a left coronary ostium and filling of the entire coronary system from the right ostial injection through collateral vessels from the right coronary artery. Surgical repair was recommended. Operative intervention showed a dysplastic bicuspid aortic valve with a membrane that covered the left coronary ostium. Excision of the membrane reestablished antegrade blood flow to the left coronary system. A follow-up exercise test revealed normal findings. Because chest pain in a young person is rarely ischemic in origin, benign or noncardiac causes are usually considered; however, if the history suggests ischemic pain, the possible presence of unusual cardiovascular abnormalities should not be disregarded.

Intra-aortic balloon counterpulsation as adjunct to aneurysmectomy in high-risk patients.

Patients with severe coronary artery disease that is not amenable to coronary artery bypass surgery face formidable risks when major aortic surgery becomes necessary. In this report we present such a patient, who successfully underwent abdominal aortic aneurysm resection and graft replacement with the prophylactic use of intra-aortic balloon counterpulsation. The use of intra-aortic balloon counterpulsation at the time of surgery has the potential of improving cardiac function in patients with left ventricular dysfunction and favorably influencing the perioperative and postoperative mortality in these patients. Its use also appears worthy of trial in patients with ruptured abdominal aortic aneurysm and shock, in the hope that it will result in improved survival in these patients.

Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990).

Acute aortic dissection is the most common fatal condition that involves the aorta; nevertheless, despite major advances in noninvasive diagnosis, the correct antemortem diagnosis is made in less than half the cases. To promote continued improvement in the prompt recognition of aortic dissection, we present a review of the Mayo Clinic experience with 235 patients who had 236 substantiated aortic dissections. At the time of initial assessment, 158 patients (67%) had acute and 78 patients (33%) had chronic aortic dissection. Hypertension was the most common predisposing factor (78% of patients overall). The acute onset of severe chest pain was the most common initial complaint (74%), but 33 patients (15%) had painless aortic dissection and abnormal chest roentgenographic findings. Less common manifestations included congestive heart failure, syncope, cerebrovascular accident, shock, paraplegia, and lower extremity ischemia. The initial clinical impression was aortic dissection in 62% of patients overall. In 17 patients (28%), the correct diagnosis was not made before postmortem examination. Although the clinical features of aortic dissection have gained wider appreciation, the diagnosis still remains unsuspected in a substantial number of patients. In a patient who has a catastrophic illness and unexplained symptoms that could be of vascular origin, especially in the presence of chest pain, aortic dissection should always be included in the differential diagnosis.

Traumatic popliteal arteriovenous fistula. Diagnostic methods and surgical management.

The popliteal vessels rank second only to the external iliac system as the most frequent site of acquired arteriovenous communication. Direct trauma to the popliteal space is by far the most common cause, and surgical intervention is usually required to manage the defect. We present a recent illustrative case following meniscectomy. To our knowledge, the occurrence of an arteriovenous fistula complicating knee surgery has not been reported previously. This case outlines the potential value of B-mode ultrasound in diagnosis and the use of intraoperative angiography in assessing the adequacy of primary vascular reconstruction. Earlier experience of this vascular abnormality--six additional cases since 1941--is reviewed.

Occlusive arterial disease of the hand due to repetitive blunt trauma: a review with illustrative cases.

OBJECTIVE: to increase clinical awareness of the role of repetitive blunt trauma, often occupational, in the development of occlusive arterial disease of the hand. STUDY DESIGN: illustrative cases are presented to emphasize the varied etiology and clinical features of occlusive arterial disease of the hand resulting from repetitive blunt trauma and an historical review of the literature is presented. RESULTS: Occlusive arterial disease of the hand due to repetitive blunt trauma is a common but often preventable disorder. The superficial location of many of the arteries of the hands and digits plus their close proximity to the bones of the hand makes them uniquely susceptible to injury from repetitive blunt trauma. An ever increasing number of occupations and leisure activities have been causally related to occlusive arterial disease of the hand. The diagnosis of occupational occlusive arterial disease due to blunt trauma is suggested by eliciting a history of repetitive blunt trauma to the hand in a patient with symptoms and/or signs of digital ischemia. The dominant hand is most commonly involved, but the non-dominant hand or both hands are affected in certain occupations. Possible predisposing or aggravating factors include tobacco use and working in a cold environment. The diagnosis of occlusive arterial disease confined to the hand or digits is confirmed by non-invasive studies in the vascular laboratory and demonstrated by arteriography. Conservative measures and protection of the hand from further trauma is sufficient for most patients, with surgical therapy being reserved for patients refractory to medical therapy or those with more severe ischemia. CONCLUSION: occlusive arterial disease of the hand may be more common than formerly thought and is often preventable by the proper use of hand tools or instruments and hand protection. This is another type of occlusive arterial disease in which tobacco may be a predisposing or aggravating factor.

Peripheral arterial disease.

Peripheral arterial diseases are common problems because atherosclerosis, the most common cause of both occlusive peripheral arterial disease and aneurysmal disease, is a feature of an aging population. The less common types of occlusive peripheral arterial disease--the vasospastic disorders and the arteritides--although frequently not addressed to any extent in medical school curricula or in residency programs in family and internal medicine, offer the alert and informed clinician diagnostic and therapeutic opportunities that are too important to neglect. As a group, abnormalities of the peripheral arteries are easy to detect if careful observation and examination of the extremities is included in the physical examination and attention to functional disorders is included in the medical history. In this presentation, the clinical features, physical findings, complications, useful noninvasive diagnostic tests, imaging techniques, and therapeutic options for atherosclerotic occlusive peripheral arterial disease (both chronic and acute), uncommon types of occlusive arterial disease of both the lower and upper extremities, the vasospastic disorders, and the peripheral arterial presentations of the arteritides are reviewed. The application of natural history and comorbidity of a particular arterial disease, when available, is emphasized in the formulation of management for the individual patient.

Chronic pernio: another cause of blue toes.

It is the purpose of this report to focus attention on the clinical features, diagnosis, and management of chronic pernio. Thirty-nine patients meeting our strict criteria for a diagnosis of chronic pernio were seen at the Mayo Clinic between 1976 and 1988 and form the basis for this report. Persons with upper extremity lesions only were excluded. Twenty-eight of the patients were female, 11 were male. Age at onset of symptoms ranged from 13 to 68 years of age, with symptoms appearing from 1 to 37 years following cold injury. The lesions were bilateral in 35 (90%) of patients and symmetric in 28 (71%). Nine patients who underwent skin temperature studies following cold water immersion, showed a vasospastic response. Chronic pernio is characterized by recurring erythematous, vesicular or ulcerative lesions of the lower extremities and toes, but may present with only digital cyanosis, usually bilateral and commonly symmetrical. The diagnosis is suggested by eliciting a temporal relation between cool weather and symptom onset, particularly if there is no associated occlusive peripheral arterial disease. Treatment consists of avoidance of cold and other vasoconstrictive influences. Prazosin has been effective in the acute management and as prophylaxis against recurrences.

Occlusive peripheral arterial disease. Guidelines for office management.

Occlusive peripheral arterial disease is rather easy to diagnose because of its characteristic symptoms and the ease with which the extremities and their circulation can be examined. Elevation and dependency tests give a rough but reliable estimate of the degree of ischemia, and if more objective data are desired, the systolic blood pressure index can be determined. Management should be individualized according to the degree of disability and ischemia, the expected natural history, and the patient's general health.

Evaluation of the patient with intermittent claudication.

The most common cause of intermittent claudication is atherosclerotic occlusive arterial disease. Differentiation of the common musculoskeletal and neurologic conditions that may mimic intermittent claudication is often possible with a careful history, but when insufficient detail is provided or multiple conditions exist, the findings on physical examination and noninvasive studies are useful. While physical examination provides a rough estimate of the degree of ischemia, assessment of functional impairment produced by occlusive arterial disease is best made with noninvasive studies before and after standard exercise. Arteriography is reserved for the patient for whom restoration of pulsatile flow is planned.