Vascular

Giant cell arteritis

PATHO

• Autoimmune vasculitis ➔ chronic inflammation of medium & large arteries (carotid and aorta)

• Inflammation ➔ narrowing ➔ ↓ blood flow ➔ ischemia

SSX

• Constitutional: Fever, night sweats, malaise, myalgia (shoulder and hip muscle pain)

  • 50% of pts with GCA have polymyalgia rheumatica

• Cranial:

  • Temporal artery (MC) ➔ hardened and tender, headache over temple

    • Jaw claudication (chewing ➔ ↑ demand ➔ ischemia ➔ pain)

  • Amaurosis fugax (ischemic optic neuropathy) and other vision changes

• Large vessel (LC) ➔ angina, ABD pain, limb claudication

DX

• ↑ ESR/CRP

• Duplex US of temporal artery shows edema and thickened vessel walls (halo) and stenotic, noncompressible artery

  • Occluded/inflamed arteries are not compressible (like veins)

• Temporal biopsy (definitive dx) shows mononuclear infiltration of vessel walls with formation of giant cells

TX

• DON'T DELAY TX FOR DEFINITIVE DX

  • Delay can ➔ irreversible vision loss

• ↑ clinical suspicion is enough to start high dose (IV) glucocorticoids

Thromboangiitis obliterans (Buerger disease)

PATHO

• Inflammatory vaso-occlusive disease of small & medium sized arteries & veins

• ♂> ♀ (3:1), ↑with smoking

• Inflammation of tunica intima ➔ microabscess (endarteritis) ➔ thrombi within lumen

  • Most of the vessel wall (media/lamina) is usually spared

• Affects distal arteries of upper and lower extremities

SSX

• Initial presentation:

  1. Intermittent claudication

  2. Raynaud phenomenon

  3. Superficial thrombophlebitis (usually migratory)

• Critical limb ischemia ➔ pain at rest ➔ gangrene

• Brachial and politeal pulses normal; weak distally

TX

• Stop smoking, wound care

• Iloprost (prostacyclin analog ➔ arterial dilation) , dihydropyridine CCB (nifedipine, amlodipine)