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 Diagnosis and Management of Miscellaneous Vasculogenic Problems

Blair A. Keagy , M.D., Mark A. Farber, M.D., Sean D. O'Donnell, M.D., John J. Ricotta, M.D.

Includes:

  • Vasospastic Diseases
  • Neurogenic Thoracic Outlet Syndrome
  • Causalgia /Reflex Sympathetic Dystrophy
  • Additional Important/Non-Core Cirriculum Topics:
  • Vasculogenic Impotence
  • Pediatric Vascular Disorders
  • Frostbite

I. Anatomy and Pathophysiology

A. Raynaud's Syndrome

1. To understand the epidemiology and pathophysiology surrounding Raynaud's Syndrome.

2. To define the epidemiologic parameters involved in Raynaud's Disease.

3. To define the physiologic mechanism occurring in Raynaud's Phenomenon.

4. To define the criteria for obstructive Raynaud's Syndrome.

5. To define the role of adrenergic receptors in the cause of Raynauds .

B. Neurogenic Thoracic Outlet Syndrome

1. To understand the anatomy of the thoracic outlet and the anatomic predisposition to developing TOS, including osseous abnormalities, and soft tissue abnormalities.

2. To understand the association of trauma, both direct and indirect, with the development of TOS.

3. To define the histological changes described in the scalene muscles of patients with TOS.

C. Causalgia /Reflex Sympathetic Dystrophy

1. To understand the pathogenesis of causalgia including that of artificial synapses, and the cycle of reflexes.

2. To define the clinical stages of Drucker , along with their characteristics and symptoms.

D. Vasculogenic Impotence

1. To describe to physiology involving erection including the blood supply, and innervation .

2. To define the differences associated with organic, psychogenic, neurogenic , and vasculogenic impotence.

E. Pediatric Vascular Disorders

1. To define and recognize the various congenital vascular lesions in children.

2. To recognize the problems associated with hemangiomas .

3. To understand renovascular hypertension in the pediatric population.

4. To understand the pathophysiology of renal vein thrombosis.

II. Diagnostic Evaluation

A. Raynaud's Syndrome

1. To understand the clinical presentation of patients with Raynaud's Syndrome. and their presenting symptoms.

2. To recognize the associated diseases.

3. To define the appropriate use of laboratory testing in the diagnosis of Raynauds , including the occlusive digital hypothermic challenge test, angiography and plethysmography .

B. Neurogenic Thoracic Outlet Syndrome

1. To define the demographic aspects of patients presenting with TOS.

2. To recognize the symptoms associated with the disease, including pain, parasthesias , and associated symptoms.

3. To recognize the musculoskeletal disorders that mimic TOS.

4. The utiliization of diagnostic tests including the Tinel and Phalen test, Adson test, and the arm stress test, and recognize the physical findings suggestive of TOS along with their sensitivity and shortcomings.

5. To understand the role of ancillary diagnostic tests in the work-up of TOS including, but not confined to, chest radiographs.

6. To recognize the need for a complete neurologic examination in these patients.

7. To define the role of electrophysiology studies in the evaluation including ulnar nerve conduction velocities, electromyography, and somatosensory evoked potentials.

C. Causalgia /Reflex Sympathetic Dystrophy

1. To understand the presenting symptoms and differential diagnosis of causalgia .

D. Vasculogenic Impotence

1. To understand the role of non-invasive vascular testing.

2. To understand the role of indirect neurologic testing in impotence.

3. To recognize the usefullness of intracavernous papaverine injection and angiography in the diagnosis of impotence.

E. Pediatric Vascular Disorders

1. To recognize the clinical presentation of renal vein thrombosis in children and its diagnostic evaluation.

III. Treatment

A. Raynaud's Syndrome

1. To recognize the medications that should be avoided in these patients.

2. To define the use of sympatholytic agents, and their replacement by calcium channel blockers.

3. To recognize the role of new therapies for treatment.

B. Neurogenic Thoracic Outlet Syndrome

1. To identify the role of conservative treatment for TOS.

2. To define the operative treatment of TOS including the choices for operative exposure, role of scalenectomy , concept of total decompression, and rationale for sparing the first rib.

3. To recognize the complications associated with the procedure including nerve, vascular, and lymphatic injuries.

C. Causalgia /Reflex Sympathetic Dystrophy

1. To define the timing of operative therapy for RSD, along with its results.

2. To identify the complications surrounding the procedure and the disease.

D. Vasculogenic Impotence

1. To understand the means of prevention of impotence during surgical procedures of the aorta and the results of appropriate revascularization.

2. To define the risk of impotence with associated vascular procedures.

3. To define the role of revascularization of the penis.

E. Pediatric Vascular Disorders

1. To define the treatment strategies for renal vein thrombosis.

2. To understand the treatment options in children with congenital vascular lesions.

References

1. Coffman JD, Cohen AS ,: Total and capillary fingertip blood flow in Raynaud's phenomenon. N Engl J Med 285:259 ,1971 .

2. Porter JM, Rivers SP, Anderson CJ, et al: Evaluation and Management of patients with Raynaud's Syndrome. Am J Surg 142:183, 1981.

3. Zweifler AJ, Trinkus P: Occlusive digital artery disease in patients with Raynaud's phenomenon. Am J Med 77:995, 1984.

4. Downs AR, Gaskell P, Morrow I, et al: Assessment of arterial obstruction in vessels supplying the fingers by measurement of local blood pressures and the skin temperature response test - Correlation with angiographic evidence. Surgery 77:530, 1975.

5. Stoney RJ, Cheng SWK: Neurogenic Thoracic Outlet Syndrome, in Rutherford RB ( ed ): Vascular Surgery. Philadelphia , PA , Saunders, 1995, pp 976-992.

6. Sanders RJ, Pearce WH: The treatment of thoracic outlet syndrome; A comparison of different operations. J Vasc Surg 10:626, 1989.

7. Rutherford R: Causalgia and Post-Traumatic Pain Syndromes, in Rutherford RB ( ed ): Vascular Surgery. Philadelphia , PA , Saunders, 1995, pp736-740.

8. Mockus MB. Rutherford RB, Rosales C, et al: Sympathectomy for causalgia : patient selection and long-term results. Arch Surg 122:668, 1987.

9. Kempczinski RF: Role of the vascular diagnostic laboratory in the evaluation of male impotence. Am J Surg 138:278, 1979.

10. DePalma RG: Impotence in vascular disease: Relationship to vascular surgery. Br J Surg 69:514, 1982.

11. Flanigan DP, Schuler JJ, Keifer T, et al: Elimination of iatrogenic impotence and improvement of sexual function after aortoiliac revascularization. Arch Surg 117:544, 1982.

12. Michal V, Kramar R, Hejhal L: Revascularization procedure of the cavernous bodies. In Zorgomotti AW, Rossi G ( eds ): Vasculogenic Impotence: Proceedings of the First International Conference on Corpus Cavernosum Revascularization. Springfield , IL , Charles C Thomas, 1980.

13. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: A classification based on endothelial characteristics. Plast Reconstr Surg 1982; 69:412-422.

14. Ricci MA, Lloyd DA. Renal venous thrombosis thrombosis in infants and children. Arch Surg 1990; 125:1195-1199.

15. Summer DS, Strandness DE Jr : An abnormal finger pulse associated with cold sensitivity. Ann Surg 175:294:1972.

16. Gates KN, Tyburczy JA, Zupan T, et al: The non-invasive quantification of digital vasospasm. Bruit 8:34 , 1984.

17. Clifford PC, Martin MFR, Sheddon EJ, et al: Treatment of vasospastic disease with prostaglandin E1. Br Med J 2:1031, 1980.

Posted June 2010