02.20 Peripheral Arterial Occlusive Disease

Question 1

Atherosclerotic occlusive disease of the arterial system distal to the aortic bifurcation

Answer 1

PAD

Question 2

Atherosclerosis commonly occurs in:

Answer 2

Aortic cusps
Branches of the aorta (subclavian and carotid)
Bifurcations (aorta to iliac artery, iliac artery to the superficial and deep femoral, anterior tibial to peroneal and posterior tibial artery, lumbar and iliac arteries

Question 3

Progression of atherosclerosis

Answer 3

Initial lesion
Fatty streak
Intermediate lesion forms
Atheroma develops
Fibroatheroma
Complicated lesion

Question 4

Histologically normal
Macrophage infiltration in sites of inflammation
Isolated foam cells

Answer 4

Inital lesion

Question 5

Intima of the vessel becomes thickened because of intracellular lipid accumulation

Answer 5

Fatty streak

Question 6

Due to intracellular lipid accumulation and small extracellular lipid pools

Answer 6

Intermediate lesion forms

Question 7

Mixture of lipid intracellular accumulations core of extracellular lipid
Stage where disease may already become overt, presenting with clinical symptoms

Answer 7

Atheroma develops

Question 8

Fibrotic or calcific layers

Answer 8

Fibroatheroma

Question 9

Because the intima is no longer smooth, there are hematoma-hemorrhages and some degree of thrombosis

Answer 9

Complicated lesion

Question 10

How lesions cause symptom

Answer 10

Stenosis/occlusion

Embolism

Question 11

Symptoms appear if _____

Answer 11

Collateral circulation is poor

Artery occludes acutely

Question 12

Leg attack

pain is felt in large muscle groups distal to an arterial lesion after exercise

Answer 12

Intermittent claudication

Question 13

Severe compromise of arterial flow
Failure of compensatory mechanisms
Exacerbated by elevation
Limb threatening

Answer 13

Ischemic rest pain

Question 14

Tissue necrosis occurs when blood flow is inadequate to maintain tissue viability even at rest

Answer 14

Gangrene

Question 15

RF for atherosclerosis

Answer 15

Tobacco use
Diet
DM
Hyperlipidemia
HPN
Fam Hx

Question 16

Important things to elicit in Hx

Answer 16

Cardiopulmonary assessment
Neurological assessment
Renal assessment

Question 17

Specific vascular evaluation

Answer 17

Inspection of skin changes
Capillary refill
Auscultate for bruits in central vessels
Pulse examination
Pulse grading

Question 18

Absence of pulse

Answer 18

0/4

Question 19

Weak (may suggest impairment)

Effort must be made to search for the pulse

Answer 19

1/4

Question 20

Normal

Answer 20

2/4

Question 21

Full

Answer 21

3/4

Question 22

Bounding (may suggest aneurysm or calcification)

Answer 22

4/4

Question 23

Classification of PAD based on the Fontaine

Answer 23

I - asymptomatic
IIa - mild claudication
IIb - moderate to severe claudication
III - ischemic rest pain
IV - ulceration or gangrene

Question 24

Classification of PAD based on Rutherford

Answer 24

00 - asymptomatic
I1 - mild claudication
I2 - moderate claudication
I3 - severe claudication
II4 - ischemic rest pain
III5 - minor tissue loss
III6 - major tissue loss

Question 25

To confirm diagnosis To establish patient baselines Assess RF of the patient

Answer 25

Non-invasive vascular testing

Question 26

Non-invasive vascular testing

Answer 26

ABI Doppler/Duplex waveform analysis Segmented pressure and waveform studies

Question 27

Normal ABI value

Answer 27

1 to a little over 1

Question 28

Reflect the degree stenosis

Answer 28

Waveforms

Question 29

Sources of error in noninvasive vascular testing

Answer 29

Wrong cuff width Incompressible arteries Operator/technician factors

Question 30

Not used solely fro diagnosis, but is generally reserved for treatment planning

Answer 30

Invasive complex imaging

Question 31

General complications of invasive complex imaging

Answer 31

``` Contrast reactions Arterial complciations Thrombosis Atheroembolism Puncture site complications ```

Question 32

Reserved for cases when there's a plan for intervention since it's already an invasive procedure

Answer 32

Conventional angiography

Question 33

Complications of conventional angiography

Answer 33

Hemorrhages or pseudo-aneursym formation at site of needle insertion Too invasive

Question 34

Still need IV needle and contrast | Can produce a 2D or #d picture

Answer 34

CT angiography

Question 35

Risks/complications of CT angiographyh

Answer 35

``` Dye-induced nephrotoxicity Dye allergy Thrombosis Atheroembolism Puncture-site ```

Question 36

Risk of MR angiography

Answer 36

Presence of any metallic objects in the body is CI

Question 37

Invasive complex imaging

Answer 37

Convetional arteriography CT angiography MR angiography

Question 38

Most important risk factor modification

Answer 38

Cessation of tobacco use

Question 39

Overall strategy in treatment of critical limb ischemia

Answer 39

Relieve ischemic pain Heal ischemic ulcers Improve patient functionality and quality of life Prolong survival

Question 40

Primary outcome of treating CLI

Answer 40

Amputation-free survival

Question 41

Common profile of CLI patients you will encounter

Answer 41

Elderly Multiple co-morbidities Non-ambulant/non-functional leg

Question 42

Medical treatment

Answer 42

Cilostazol | Pentoxphylline

Question 43

In patients with limb threat

Answer 43

Revascularization

Question 44

Revascularization procedure

Answer 44

Percutaneous endovascular intervention Surgical revascularization Medical vascularization

Question 45

Percutaneous endovascular intervention

Answer 45

Angioplasty Atherectomy Stenting

Question 46

Surgical revascularization

Answer 46

Enderarterectomy | Bypass surgery

Question 47

Indications for surgical management

Answer 47

Gangrene Pain at rest Non-healing arterial ulcer Disabling claudication

Question 48

Gold standard | Established long-term patencies, lim salvage and mortality outcomes

Answer 48

Operative bypass | Open surgical revascularization

Question 49

First line teratment | Minimally invasive, more tolerated by sick patients

Answer 49

Angioplasty | Stenting

Question 50

Minimally invasive endovascular techqnies for infra-inguinal disease

Answer 50

``` Percutaneous angioplasty PTA with stenting Atherectomy Subintimal angioplasty Percutaneous endografting ```

Question 51

Intermediate-term outcome of angioplasty, when used preferentially for critical ischemia in anatomically suitable patients, provides very acceptable limb salvage and survival despite a relatively high stenosis rate

Answer 51

Primary angioplasty for critical limb ischemia

Question 52

Use of VEGF and basic FGF to promote collaterall circulation growth

Answer 52

Medical revascularization

Question 53

Single stenosis < 1 cm in length Endovascular treatment Endovascular

Answer 53

TASC-A

Question 54

Multiple stenosis focal, each < 1 cm in length Endovascular therapy is the preferred treatment even in long lesions or tandem lesions Endovascular therapy is preferred treatment

Answer 54

TASC-B

Question 55

Stenoses 1-4 cm in length Short occlusions < 2cm in length Surgery

Answer 55

TASC-C

Question 56

Diffuse long stenosis < 4 cm in length Occlusions > 2cm in length Surgery

Answer 56

TASC-D