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ANKI Cardiovascular > [13] Peripheral Arterial Disease > Flashcards

[13] Peripheral Arterial Disease Flashcards

1
Q

What is peripheral arterial disease?

A

A condition where there is significant narrowing of the arteries distal to the arch of the aorta, most often due to atherosclerosis

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2
Q

What is the clinical relevance of PAD?

A

Patients diagnosed as having PAD, inclduing those who are asymptomatic, are at increased risk of mortality, myocardial infarction, and stroke

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3
Q

What is the most severe manifestation of PVD affecting a limb?

A

Critical limb ischaemia

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4
Q

What is critical limb ischaemia? q

A

A chronic condition defined as the presence of ischaemic rest pain, and ischaemic lesions or gangrene objectively attributable to arterial occusive disease

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5
Q

What are the risk factors for peripheral arterial disease?

A
  • Smoking
  • Diabetes mellitus
  • Hypertension
  • Hyperlipidaemia
  • Physical inactivity
  • Obesity
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6
Q

What are the symptoms of peripheral arterial disease?

A
  • Intermittent claudication
  • Leriche’s syndrome
  • Ischaemic rest pain
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7
Q

What is intermittent claudication?

A

Muscle pain in the lower limbs on exercise

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8
Q

What are the features of intermittent claudication?

A
  • Walking impairment
  • Symptoms relieved by rest
  • Pain comes on more rapidly when walking uphill than walking on flat
  • Often worse in leg
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9
Q

What walking impairment may be present in intermittent claudication?

A
  • Fatigue
  • Aching
  • Cramping
  • Pain in buttock, thigh, calf, or foot
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10
Q

What is Leriche’s syndrome?

A

Pain similar to intermittent claudication in the buttocks and thighs, associated with absent femoral pulses and male impotence

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11
Q

What is ischaemic rest pain?

A

Severe, unremitting pain in the foot, particularly at night

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12
Q

How might ischaemic rest pain be partially relieved by the patient?

A

By hanging the foot out of the bed

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13
Q

Where does ischaemic rest pain occur?

A

In severe, extensive PVD

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14
Q

What are the examination signs of PVD?

A
  • Affected leg may be pale and cold, with loss of hair and skin changes
  • May be poorly healing wounds of the extremities
  • May be ulceration or gangrene in severe cases
  • Weak or absent femoral, popliteal, dorsalis pedis, and posterior tibial pulse
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15
Q

What are the differential diagnoses of PVD?

A
  • Sciatica
  • Spinal stenosis
  • Deep vein thrombosis
  • Entrapment syndromes
  • Muscle/tendon injury
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16
Q

What assessment should any patient suspected as having PAD have?

A

A full cardiovascular risk assessment

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17
Q

What is included in a full cardiovascular risk assessment?

A
  • BP
  • FBC
  • Fasting blood glucose
  • Lipid levels
  • ECG
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18
Q

What % of people with intermittent claudication are found to have ECG evidence of pre-existing CVD?

A

60%

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19
Q

What additional investigations should PVD patients under the age of 50 have?

A
  • Thombophilia screen
  • Serum homocysteine levels
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20
Q

What is the main method of confirmation of a diagnosis of PVD?

A

Doppler ultrasonography

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21
Q

What is the role of duplex ultrasonography in the investigation of PVD?

A

It can determine the site of disease, and indicate the degree of stenosis and length of occlusion

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22
Q

What is the ABPI?

A

The ratio of systolic blood pressure at the ankle and the arm

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23
Q

What does the ABPI provide a measure of?

A

Blood flow at the ankle

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24
Q

What is a normal ABPI?

A

1

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25
Q

What ABPI indicates claudication?

A

0.6-0.,9

26
Q

What ABPI indicates impending gangrene?

A

>0.3

27
Q

Other than ultrasound, what imaging methods can be used in the investigation of PVD?

A
  • MR angiography
  • CT angiography
28
Q

What diseases are associated with PVD?

A
  • Coronary heart disease
  • Cerebrovascular disease
  • Diabetes
29
Q

What are the criteria for referral to secondary care in PVD?

A
30
Q

Is invasive intervention always required in the management of PVD?

A

No, most patient’s symptoms improve with optimal medical treatment

31
Q

Is the course of PVD variable?

A

Yes

32
Q

What intervention is sufficient to improve symptoms for many patients?

A
  • Lifestyle changes
  • Medical management
33
Q

What % of PVD patients will deteriorate and develop critical limb ischaemia?

A

Approximately 20%

34
Q

How can cardiovascular risk factors be modified in PVD?

A
  • Smoking cessation
  • Regular exercise
  • Lipid-lowering drugs
  • Management of hypertension
  • ACE inhibitors
  • Management of diabetes mellitus
35
Q

How can patients be helped to do regular exercise in the management of PVD?

A

A supervised exercise programme which comprises of 2 hours of exercise per week for a 3 month period should be offered to all patients with PVD

36
Q

What is the trade-off with the management of hypertension in PVD?

A

It provides a long term benefit, but in the short term may worsen intermittent claudication

37
Q

What effect have ACE inhibitors been shown to produce in PVD patients?

A

Shown to reduce cardiovascular morbidity and mortality

38
Q

Why should caution be taken when using ACE inhibitors in PVD?

A

Over 25% of PVD patients have renal artery stenosis

39
Q

When is antiplatelet therapy recommended in PVD?

A

For those with symptomatic PVD

40
Q

What is recommended as the anti-platelet agent in PVD?

A

Clopidogrel

41
Q

What is the purpose of clopidogrel in PVD?

A
  • It prevents occlusive vascular events
  • Reduce incidence of major cardiovascular events
42
Q

Why is clopidogrel preferred to aspirin in PVD?

A

It is at least as effective as aspirin, and has a better side-effect profile

43
Q

What is naftidrofuryl oxalate?

A

An oral peripheral vasodilator

44
Q

Where is naftidrofuryl oxalate recommended in PVD?

A

As an option for treatment of intermittent claudication in people with PVD, when supervised exercise has not lead to a satisfactory impovement, and the patient does not want surgery

45
Q

When is revascularisation essential in PVD?

A

In patients with critical limb ischaemia

46
Q

How useful is revascularisation surgery in mild-to-moderate claudication?

A

It has not been shown that revascularisation is superior to exercise and best medical treatment in patients with mild-to-moderate claudication

47
Q

What are the indications for surgery in PVD?

A
  • Disabling claudication
  • Critical limb ischaemia
  • Weak or absent femoral pulses
48
Q

How long after diagnosis of critical limb ischaemia should revascularisation surgery be attempted?

A

Without delay

49
Q

What are the surgical options for revascularisation in critical limb ischaemia

A
  • Angioplasty and stening
  • Bypass surgery and grafts
50
Q

What should the decision about wether to perform angioplasty or bypass surgery in PVD take into account?

A
  • Co-morbidities
  • Pattern of disease
  • Availability of a vein
  • Patient preference
51
Q

What are the amputation rates in critical limb ischaemia?

A

5-20%

52
Q

When is amputation considered in critical limb ischaemia?

A

Mainly in patients unsuitable for revascularisation, neurologically impaired, or non-ambulatory

It should only be offered to patients when all options for revascularisation have been considered

53
Q

Which surgical approach to revascularisation is generally favoured?

A

Angioplasty and stenting

54
Q

Why is angioplasty and stenting generally favoured?

A

Due to reduced morbidity and mortality

55
Q

What is the major drawback of endovascular internentions (angioplasty and stenting) compared with surgery (bypass grafting)?

A

Lower long-term patency

56
Q

Which lesions is the patency after angioplasty and stenting greatest?

A

Those in the common iliac artery, and then patency decreases distally

57
Q

What factors reduce the change of long-term patency after angioplasty?

A
  • Increasing length
  • Multiple and diffuse lesions
  • Poor-quality run off
  • Diabetes
  • Chronic kidney disease
58
Q

When should angioplasty be offered to people with intermittent claudication?

A

When risk factor modification has been discussed, supervised exercise has failed to improve symptoms, and imaging shows angioplasty is suitable for the patients

59
Q

When is bypass grafting typically used in PVD?

A

Diffuse disease

60
Q

When should bypass surgery be offered to people with intermittent claudication?

A

Only in people with severe, lifestyle-limiting intermittent claudication, when angioplasty has been unsuccessful or is unsuitable, and imaging has confirmed that bypass surgery is appropriately for the person

61
Q

What is the effect of PVD on quality of life?

A

Quality of life is often significantly impaired, particularly as a result of reduced mobility

62
Q

What are the potential complications of PVD?

A
  • Acute limb ischaemia may result from thrombosis arising within a peripheral artery or from embolic occlusion
  • Infection and poor healing of tissue with reduced blood supply
  • Ulceration
  • Gangrene
  • Amputation
  • Multi-organ dysfunction

ANKI Cardiovascular (24 decks)

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