FIRST COAST CARDIOVASCULAR INSTITUTE

Three Case Presentations FOMA D II +MHJ Symposium

Majdi Ashchi, DO,FACC,FSCAI,FABVM

Victoria Kozel ARNP-BC

April 14, 2011

Learning Objectives

• Diagnose & Treat : venous insufficiency, coronary aneurysm, FMD and pseudotumor cerebri.

• Describe symptoms and clinical presentation of venous insufficiency and pseudotumor cerebri patients.

• Explain treatment options for venous insufficiency, FMD, coronary artery aneurysm and pseudotumor cerebri.

Case 1 – Leg Fatigue • 36 y.o. WF presented with history of

generalized leg fatigue for few years. She is a runner, exercises 5 times a week doing cardiovascular training.

• Onset of symptoms – gradual, now most evident. Reports has “no energy” overall.

• Associated symptoms: mild ankle swelling at the end of the day, dysmenorrhea, mid-cycle spotting.

Case 1 – Leg Fatigue

• PMH – mildly overweight, otherwise negative.

• SH – non-smoker, no alcohol, no drugs. She is married, 3 healthy children. Worked as waitress in the past, currently unemployed – home-schools her children.

• ?????? - diagnosis

Case 1 – Leg Fatigue

• Differential Diagnoses:

– Pelvic congestion syndrome

– Anemia, Hypothyroid, etc

– Depression – psychosomatic disorder

– DVT

– Musculoskeletal Disorders: referred back/hip pain

– CHF

– Pelvic mass/cancer

Case 1 – Leg Fatigue

Work – up prior to presentation to FCCI office:

1. Venous u/s duplex

2. Pelvic u/s

3. Blood work

4. GYN and a trial of tricyclics

NOW

What else should we look for?

Case 1 – Leg Fatigue Further work-up included :

a full venous insufficiency study

- bilateral grade III venous reflux

Treatment:

- Conservative measures

- Venous Ablation ( Laser vs RFA)

- Sclerotherapy

- Phlebectomy

_

Case 1 – Leg Fatigue

• Results:

– Successful treatment of Incompetent Venous System with LASER ablation.

– Complete resolution of her symptoms

– No longer fatigued

– Off antidepressants

– No GYN issues any more

Venous Insufficiency

• Definition

• Risks: here are a few

– Obesity/overweight

– Standing/sitting jobs

– Family history

– Pregnancy

• CEAP Classification

• Treatment Options

Case 2 – Patient with CAD

• 68 yo WM, retired Police officer

• Hx of Coronary Stents to LAD, CX 2008

• On cardiac cath film, a large RCA with 8mm dilatation of artery c/w aneurysm

• Patient remained asymptomatic over the next 2 yrs until routinely NST came back abnormal.

Case 2 – Patient with CAD

• Symptoms:

– Exertional Dyspnea – concerning for angina equivocal symptoms. No true chest pain.

• PMH: HTN, dyslipidemia, obesity, CAD, carotid disease.

• SH: former smoker, admits to occasional beer, no hx of drug use.

What is the next step ??

Case 2 – Patient with CAD

• Patient underwent successful covered stent placement of RCA aneurysm.

• He will need to continue with yearly stress testing and office follow-up visits.

Case 2 – Coronary Artery Aneurysm

• Definition: coronary dilatation exceeding diameter of normal artery segments or diameter of patient’s largest coronary vessel by 1.5 times.

• It is fairly uncommon, but increasing in incidence.

• Causes: ??? Previous Radiations, infections, Kawasaki, etc….

RCA aneurysm

RCA

Case 2 – Coronary Artery Aneurysm

Potential complications

- rupture

- distal embolization

- thrombosis

- vasospasm

Treatment

- medical therapy vs. surgical intervention

- Covered Stent

catheter

Aneurysm RCA

Aneurysm

Covered with

Atrium Stent

Coronary Aneurysm

BEFORE COVERED STENT AFTER COVERED STENT

Case 3 – Carotid Bruit

• 57 yo white female presented for a pre-op cardiac clearance pending a knee surgery. On physical exam she was noted to have a harsh bilateral carotid bruit.

• Denies: dizziness

– Syncope

– Decrease in memory

– No neurological symptoms

Case 3 – Carotid Bruit • PMH:

– Hypertension

– Hyperlipidemia

– Asthma

– Psoriatic arthritis

– Fibromyalgia

SH:

Smokes 1 ½ ppd, denies alcohol, no drug use.

Case 3 – Carotid Bruit

• Denies any neurological symptoms.

• She had an abnormal Nuclear stress test and is now facing cardiac catheterization to assess for obstructive coronary artery disease.

• What is the next appropriate step ?

re: carotid bruit in an asymptomatic patient?

Case 3 – Carotid Bruit

• Yes, carotid u/s duplex study:

– Was positive for elevated velocities bilateral ICA >250 cm/sec

– Her carotid angiogram was consistent with mild bilateral ICA stenosis, however, added a small surprise to her case…

FMD, wringled artery

Case 3 – Carotid Bruit

• FMD (Fibromuscular Dysplasia)-hyperplastic disorder affective medium-sized and small arteries.

– Females>males

– Usually involves renal and carotid arteries

– ID via angiography or US duplex “string of beads”

TREATMENT

- Neuroradiology was consulted

Case 4 – Blurred Vision

• 26 yo white female presents with blurred vision for 1 week, now constant. Other symptoms included: occasional headaches and nausea. Denies any speech changes, no dizziness or syncope.

– No muscle weakness

– No gait or memory changes

Case 4 – Blurred Vision

• PMH:

– obesity

– Mild seasonal allergies

– Negative for HTN, dyslipidemia, DM, autoimmune disorders

SH: non-smoker, no alcohol or drug use.

… Differential Diagnoses???

Case 4 – Blurred Vision • Differential Diagnoses:

– Migraine

– Thrombus

– Cancer/brain tumor

– infection

– Meningitis

– Glaucoma

Work-up:

physical exam, CT/MRI, lumbar puncture/spinal tap

Case 4 – Blurred Vision

• Ok, Final Diagnosis?

• MRI of the head was consistent with pseudotumor cerebri

• Treatment: successful

– diuretics

– Weight loss

– Avoiding contraceptives and steroids

Case 4 – Blurred Vision

• Pseudotumor cerebri is one of several

names given to syndrome of prolonged increased intracranial pressure without focal neurological symptoms or signs, and in which the cerebrospinal fluid is of normal composition.

Case 4 – Blurred Vision-Pseudotumor Cerebri: etiology is unknown

• Potential associated factors:

– Iron-deficiency anemia

– Obesity/overweight

– Cushing’s disease/ckf

– Hypothyroid/parathyroid

– Pregnancy

– Vit-A deficiency/overabundance

– medications

• Symptoms

– Headache

– Tinnitus

– Dizziness

– Nausea

– Diplopia

– Vision loss

References • Braunwald, E. et al. (2001). Principles of Internal Medicine. (15th Ed.). McGraw-Hill: New

York. Pp. 1436-1437.

• Brazis, P. W. (2009). Surgery for Idiopathic Intracranial Hypertension. Journal of Neuro-Ophthalmology, 29(4), 271-274.

• Kesler, A., Goldhammer, Y. & Gadoth, N. (2001). Do Men With Pseudotumor Cerebri Share the Same Characteristics as Women? A Retrospective Review of 141 Cases. Journal of Neuro-Ophthalmology, 21(1), 15-17.

• Nichols, L., Lagana, S. & Parwani, A. (2008). Coronary Artery Aneurysm: A Review and Hypothesis Regarding Etiology. Arch Pathol Lab Med, 132, 823-828.

• Owler, B. K. et al. (2003). Pseudotumor Cerebri Syndrome: Venous Sinus Obstruction and Its Treatment With Stent Placement. Journal of Neurosurgery, 98(5),

• Ramankutty, R. , Albacker, T. B. & Navia, J. L. (April, 2010). Successful Management of a Posterior Saccular Coronary Artery Aneurysm at the Left Main Coronary Artery Bifurcation. Journal of Cardiac Surgery, 26(1), 37-39.

• Syed, M. & Lesch,M. (1997). Coronary Artery Aneurysm: A Review. Progress in Cardiovascular Diseases. 40(1), 77-84.

• Walker, E. & Adamkiewicz, J. J. (1964). Pseudotumor Cerebri Associated With Prolonged Corticosteroid Therapy. JAMA 188(9), 779-784.

Questions ???