Arterial insufficiency is a lack of enough blood flow through the arteries.

See also:

• Arterial embolism
• Coronary artery disease
• Mesenteric artery ischemia
• Peripheral artery disease
• Stroke
• Venous insufficiency

One of the most common causes of arterial insufficiency is atherosclerotic disease.

Arterial insufficiency can affect many different parts of the body. The specific symptoms may indicate which artery is involved.

If heart arteries are involved, it can cause symptoms of heart attack.

If brain arteries are involved, it can cause symptoms of stroke.

If the arteries of the lower abdomen or legs are involved, you might have repeated episodes of leg cramping when you walk.

Arterial insufficiency also can affect the arteries in the abdomen, causing pain after you eat meals.

Goldman L. Approach to the patient with possible cardiovascular disease. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 48.

A cerebral arteriovenous malformation is an abnormal connection between the arteries and veins in the brain that usually forms before birth.

AVM - cerebral

The cause of cerebral arteriovenous malformation (AVM) is unknown. The condition occurs when arteries in the brain connect directly to nearby veins without having the normal vessels (capillaries) between them.

Arteriovenous malformations vary in size and location in the brain.

An AVM rupture occurs because of pressure and damage to brain tissue, as well as a lack of blood flow to the brain. Symptoms may also occur when large AVMs that have not bled press on the brain tissue.

Cerebral arteriovenous malformations occur in less than 1% of people. Although the condition is present at birth, symptoms may occur at any age. Hemorrhages occur most often in people ages 15 - 20, but can also occur later in life. Some patients with an AVM also have cerebral aneurysms.

Symptoms that may occur with an AVM that has not bled include:

• Decreased sensation in any part of the body
• Headache
  • In one area (localized) or general
  • Resembles a migraine headache in some cases
• Muscle weakness, any part of the body
• Seizures
  • Generalized tonic-clonic seizure
  • Partial (focal) seizure
• Vision changes
  • Blurred vision
  • Decreased vision
  • Double vision

Additional symptoms:

• Decreased consciousness
• Dizziness
• Dysfunctional movement
• Ear noise/buzzing
• Eyelid drooping
• Facial paralysis
• Fainting
• Impaired smell
• Speech impairment

There are often no symptoms until the AVM ruptures. This results in sudden bleeding in the brain (hemorrhagic stroke). In more than half of patients with AVM, hemorrhage is the first symptom. Symptoms of AVM hemorrhage are the same as those of other intracerebral hemorrhage.

A complete physical examination and neurologic examination are needed, but they may be completely normal.

Tests that may be used to diagnose an AVM include:

• Cerebral angiogram
• Cranial MRI
• Electroencephalogram (EEG)
• Head CT scan
• Magnetic resonance angiography (MRA)

A bleeding AVM is a medical emergency. The goal of treatment is to prevent further complications by controlling bleeding and seizures and, if possible, removing the AVM.

Treatments include:

• Open brain surgery
• Endovascular treatment
• Radiosurgery

Some treatment options are used together.

Open brain surgery removes the malformation through an opening made in the skull. It must be done by a highly skilled neurosurgeon.

Embolization (endovascular treatment) is the injection of a glue-like substance into the abnormal vessels to stop blood flow in the AVM and reduce the risk of bleeding. This may be the first choice for some kinds of AVMs, or if surgery cannot be done.

Stereotactic radiosurgery is another alternative. This procedure delivers radiation directly to the area of the AVM to cause scarring and shrinkinge. It can control bleeding and other symptoms. It is particularly useful for small deep AVMs, which are difficult to remove by surgery.

Anti-convulsant medications, such as phenytoin, are usually prescribed if seizures occur.

Approximately 10% of cases in which hemorrhage is the first symptom are deadly. Some patients may have permanent seizures and neurological problems.

• Focal weakness
• Intracerebral hemorrhage
• Language difficulties
• Numbness of any part of the face or body
• Permanent neurologic changes such as paralysis or sensory problems
• Persistent headache
• Seizures
• Subarachnoid hemorrhage
• Vision changes
• Water on the brain (hydrocephalus)

Possible complications of open brain surgery include:

• Brain swelling
• Hemorrhage
• Seizure
• Stroke

Go to the emergency room or call the local emergency number (such as 911) if you have:

• Numbness in parts of the body
• Seizures
• Severe headache
• Vomiting
• Weakness
• Other symptoms of a ruptured arteriovenous malformation

Also seek medical attention if you have a first ever seizure, because AVM is occasionally the cause of seizures.

Zivin JA. Hemorrhagic cerebrovascular disease. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 237: chap 432.

Arterial embolism is a sudden interruption of blood flow to an organ or body part due to a clot (embolus).

An embolus is a blood clot or a piece of plaque that acts like a clot. Emboli means more than one clot. If the clot travels from the site where it formed to another location in the body, it is called an embolism.

An arterial embolism may be caused by one or more clots. The clots can get stuck in an artery and block blood flow. The blockage starves tissues of blood and oxygen, which can result in damage or tissue death (necrosis).

Arterial emboli often occur in the legs and feet. Some may occur in the brain, causing a stroke, or in the heart, causing a heart attack. Less common sites include the kidneys, intestines, and eyes.

Atrial fibrillation is a major risk factor for arterial embolism. The risk of an embolism increases when factors that tend to form clots are increased. Such factors include injury or damage to an artery wall and conditions that increase blood clotting (such as increased platelet count).

Another condition that poses a high risk for embolization (especially to the brain) is mitral stenosis. Endocarditis (infection of the inside of the heart) can also cause arterial emboli.

A common source for an embolus is from areas of hardening (atherosclerosis) in the aorta and other large blood vessels. These clots can break loose and flow down to the legs and feet.

Paradoxical embolization can take place when a clot in a vein enters the right side of the heart and passes through a hole into the left side. The clot can then move to an artery and block blood flow to the brain (stroke) or other organs.

If a clot involves the arteries supplying blood flow to the lungs, it is called a pulmonary embolus.

Symptoms may begin quickly or slowly depending on the size of the embolus and how much it blocks the blood flow.

Symptoms of an arterial embolism in the arms or legs may include:

• Cold arm or leg
• Decreased or no pulse in an arm or leg
• Fingers or hands feel cool
• Lack of movement in the arm or leg
• Muscle pain in the affected area
• Muscle spasm in the affected area
• Numbness and tingling in the arm or leg
• Pale color of the arm or leg (pallor)
• Weakness of an arm or leg

Later symptoms:

• Blisters of the skin fed by the affected artery
• Shedding (sloughing) of skin
• Skin erosion (ulcer)
• Tissue death (necrosis; skin is dark and damaged)

Symptoms of a clot in an organ vary with the organ involved but may include:

• Pain in the part of the body that is involved
• Temporarily decreased organ function

The health care provider may find decreased or no pulse, and decreased or no blood pressure in the arm or leg. There may be signs of tissue death or gangrene.

Tests to diagnose arterial embolism or reveal the source of emboli may include:

• Angiography of the affected extremity or organ
• Doppler ultrasound exam of an extremity
• Duplex Doppler ultrasound exam of extremity
• Echocardiogram
• MRI
• Myocardial contrast echocardiography (MCE)
• Plethysmography
• Transcranial Doppler exam of arteries to the brain
• Transesophageal echocardiography (TEE)

This disease may also affect the results of the following tests:

• Euglobulin lysis time (ELT)
• Factor VIII assay
• Isotope studyof the affected organ
• Plasminogen activator inhibitor-1 (PAI-1) activity
• Platelet aggregation test
• Tissue-type plasminogen activator (t-PA) levels

Arterial embolism requires prompt treatment at a hospital. The goals of treatment are to control symptoms and to improve the interrupted blood flow to the affected area of the body. The cause of the clot, if found, should be treated to prevent further problems.

Medications include:

• Anticoagulants (such as warfarin or heparin) can prevent new clots from forming
• Antiplatelet medications (such as aspirin, ticlopidine, and clopidogrel) can prevent new clots from forming
• Painkillers given through a vein (by IV)
• Thrombolytics (such as streptokinase) can dissolve clots

Some people need surgery. Procedures include:

• Bypass of the artery (arterial bypass) to create a second source of blood supply
• Clot aspiration(thromboaspiration)
• Clot removal through a balloon catheter placed into the affected artery or through open surgery on the artery (embolectomy)
• Opening of the artery with a balloon catheter (angioplasty) with or without a stent implanted

How well a patient does depends on the location of the clot and how much the clot has blocked blood flow. Arterial embolism can be serious if not treated promptly.

The affected area can be permanently damaged. Up to approximately 25% of cases require amputation.

Arterial emboli can come back (recur) even after successful treatment.

• Acute MI
• Infection in the affected tissue
• Septic shock
• Stroke(CVA)
• Temporary or permanent decrease or loss of other organ functions
• Temporary or permanent kidney failure
• Tissue death (necrosis) and gangrene
• Transient ischemic attack (TIA)

Go to the emergency room or call the local emergency number (such as 911) if you have symptoms of arterial embolism.

Prevention begins with identifying the source of the blood clot. If your health care provider determines you have a high risk for blood clots, you may be prescribed blood thinners (such as warfarin or Coumadin) to prevent them from forming. Antiplatelet drugs may also be needed.

The risk for both atherosclerosis and clot formation increases in persons who:

• Are inactive and do little exercise
• Are overweight
• Are under stress
• Smoke

Taking steps to reduce hardening of the arteries (atherosclerosis) may reduce your risk of an arterial embolus forming from a piece of plaque.

Clagett GP, Sobel M, Jackson MR, Lip GY, Tangelder M, Verhaeghe R. Antithrombotic therapy in peripheral arterial occlusive disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3):609S-626S.

Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic). Circulation. 2006;113:e463-e654.

Goldman L. Approach to the patient wtih possible cardiovascular disease. In: Goldman L, Ausiello D. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 48.

An arteriogram is an imaging test that uses x-rays and a special dye to see inside the arteries. It can be used to see arteries in the heart, brain, kidney, and many other parts of the body.

The procedure is often called angiography.

See also:

• Aortic angiography
• Cerebral angiography
• Coronary angiography
• Extremity arteriography
• Fluorescein angiography
• Lymphangiogram
• Pulmonary angiography
• Renal arteriography

Angiogram; Angiography

The test is done in a medical facility designed to perform this test. The exact procedure depends on the part of the body being examined.

You may receive a sedative to help you relax.

In general, a dye called contrast material is injected into an artery or vein, depending on the body part being examined. Injection into an artery takes more preparation and care, and is most often done through the groin. X-rays are taken to see how the dye flows through your bloodstream.

How you should prepare depends on the part of the body being examined. Your health care provider may tell you to stop taking certain drugs that could affect the test. In most cases, you may not be able to eat or drink anything for a few hours before the test.

You may have some discomfort from a needle stick. Depending upon the type of arteriogram being performed, you may have a variety of symptoms when the health care provider injects the contrast material. For example, you may have flushing in the face or other parts of the body.

If you had an injection in your groin area, you will usually be asked to lie flat on your back for a few hours after the test to avoid bleeding. This may cause some back discomfort.

An arteriogram is done to see how blood moves through the arteries, and to check for any blocked or damaged arteries. Sometimes, treatments can be done at the same time as an arteriogram.

The risks depend on the type of arteriogram performed. You should ask your doctor about the risks before you agree to have the test performed.

In general, risks may include:

• Allergic reaction to the dye used
• Bleeding, infection, and pain at the injection site
• Blood clots
• Damage to blood vessels
• Damage to the kidneys from the dye used (higher risk in those with diabetes)

An arterial stick is the collection of blood from an artery for laboratory testing.

Blood sample - arterial

Usually the blood is drawn from the wrist. However, it may also be drawn from the inside of the elbow, groin, or other artery. A heartbeat (pulse) is felt by pressing on the area above an artery. The doctor will usually check to make sure blood is flowing into the hand from the main arteries in the forearm (radial and ulnar arteries).

The area is cleaned with antiseptic and a needle is inserted. A small amount of anesthetic may be injected or applied before the needle is inserted. The blood will easily flow into the specially prepared (heparinized) syringe.

The needle is removed after there is enough of a blood sample. Pressure is applied to the puncture site for 5 - 10 minutes to stop the bleeding. You will be checked during this time to make sure the bleeding stops.

Preparation varies with the specific test performed.

Puncture of an artery may be somewhat more uncomfortable than puncture of a vein, because arteries are deeper than veins, have thicker walls, and have more nerves. Also, firm pressure must be placed over the site after the blood is drawn.

When the needle is inserted, most people feel moderate discomfort or pain. Afterward, there may be some throbbing.

Blood transports oxygen, food, waste products, and other materials within the body. It also regulates body temperature, fluids, and the balance of acids and bases.

Blood is made up of a fluid portion (plasma) and a cellular portion. Plasma contains various substances dissolved in the fluid. The cellular portion is made up mainly of red blood cells, but it also includes white blood cells and platelets.

Because blood has many functions within the body, tests on the blood or its components may give valuable clues to help doctors diagnose many medical conditions.

Blood in the arteries (arterial blood) differs from blood in the veins (venous blood) mainly in its content of dissolved gases. Testing arterial blood shows the make-up of the blood before any of its contents are used by the body tissues.

See specific tests, particularly the arterial blood gas test.

Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific test results.

An arterial stick is done to get blood samples from arteries. Arterial blood samples are mainly taken to measure arterial blood gases (which may indicate breathing problems or metabolic disorders). However, arterial sticks may sometimes be done to get blood culture or blood chemistry samples.

Veins and arteries vary in size from one patient to another and from one side of the body to the other. Obtaining a blood sample from some people may be more difficult than from others.

Other risks associated with having blood drawn are slight but may include:

• Excessive bleeding
• Fainting or feeling light-headed
• Hematoma (blood accumulating under the skin)
• Bruising
• Infection (a slight risk any time the skin is broken)

There is a slight risk of damage to nearby tissues when the blood is drawn. Blood can be taken from lower-risk sites, and techniques are used to minimize tissue damage.

If blood is easier to get from one location or side of your body, let the person who is drawing your blood know before starting the test.

Mizma D, Janchar T. Arterial puncture and cannulation. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: Saunders Elsevier;2004:chap 20.