148: Cutaneous Changes in Arterial, Venous, and Lymphatic Dysfunction Flashcards
1
Q
What is the most classic symptom of obstructive peripheral arterial disease (PAD)?
A
The most classic symptom of obstructive peripheral arterial disease (PAD) is intermittent claudication, which is characterized by pain, fatigue, or tiredness in a defined muscle group distal to the diseased vascular segment upon walking, relieved by rest.
2
Q
What are the common cutaneous findings associated with obstructive peripheral arterial disease?
A
Common cutaneous findings in obstructive peripheral arterial disease include:
- Intermittent claudication: limbs appear normal, but associated clinical findings may include hair loss, coldness, cyanosis, and/or thickened and malformed toenails.
- Rest pain: foot appears bright red and cold in dependency, with severe ischemia leading to atrophic, dry, and shiny skin.
- Ulcerations: often start at the tips of the toes or heel, extremely painful, with irregular borders and a pale base, and may show signs of infection.
3
Q
What are the hallmark noncutaneous findings in peripheral arterial disease (PAD)?
A
The hallmark noncutaneous findings in peripheral arterial disease (PAD) include:
- Decreased or absent pulses distal to the stenotic arterial segment.
- Bruits on auscultation, indicating turbulent flow.
- Normal palpable pulses in intermittent claudication, which can be assessed by having the patient walk or perform toe raises to reproduce symptoms and then palpate for pulses.
4
Q
What is the significance of the ‘5 Ps’ in acute limb ischemia?
A
The ‘5 Ps’ include severe pain, pallor, pulselessness, paresthesias, and paralysis, indicating critical limb ischemia.
5
Q
What is a hallmark noncutaneous finding in PAD?
A
Decreased or absent pulses distal to the stenotic arterial segment.
6
Q
What does the presence of ulcers in PAD typically indicate?
A
Ulcers most often start at the tips of the toes or on the heel of the foot and are extremely painful, indicating severe ischemia.
7
Q
What is the epidemiological prevalence of PAD in individuals aged 65 and older?
A
Up to 20% of individuals older than age 65 are affected by PAD.
8
Q
What is the expected resolution time for symptoms of intermittent claudication after rest?
A
Symptoms typically resolve within several minutes of rest.
9
Q
What is the relationship between collateral circulation and PAD symptoms?
A
Inadequate collateral circulation can lead to cold extremities, rest pain, and skin breakdown, worsening PAD symptoms.
10
Q
What is the clinical significance of the time taken for foot veins to fill in PAD assessment?
A
Veins should fill within 20 seconds; if it takes longer than 30 seconds, it indicates inadequate circulation and potential complications.
11
Q
What are the common demographic characteristics of PAD patients?
A
PAD is more common in individuals aged 40 to 59 years, with a higher incidence in females rapidly after menopause.
12
Q
A 65-year-old patient presents with intermittent claudication and a history of smoking. What is the most likely diagnosis, and what is the hallmark noncutaneous finding?
A
The most likely diagnosis is Peripheral Arterial Disease (PAD). The hallmark noncutaneous finding is decreased or absent pulses distal to the stenotic arterial segment.
13
Q
What are the five components of the pentad of acute limb ischemia?
A
The pentad includes severe pain, pallor, pulselessness, paresthesias, and paralysis.
14
Q
A patient with PAD has ulcerations on the tips of their toes. What are the characteristic features of these ulcers?
A
The ulcers have irregular borders, a pale base, and are extremely painful unless diabetic neuropathy is present.
15
Q
What are the key clinical features of acute limb ischemia as defined by the ‘5 Ps’?
A
The key clinical features of acute limb ischemia include:
1. Severe pain - usually persistent at rest
2. Pallor - pale appearance of the limb
3. Pulselessness - absence of pulse in the affected limb
4. Paresthesias - abnormal sensations such as tingling
5. Paralysis - weakness or inability to move the limb
6. Poikilothermia - a cold extremity
7. Neurologic symptoms - indicates severe ischemia and need for emergent evaluation.
16
Q
How does intermittent claudication differ from rest pain in patients with peripheral arterial disease?
A
Intermittent Claudication:
- Symptoms: Pain, fatigue, or tiredness in a defined muscle group distal to the diseased vascular segment upon exertion, relieved by rest.
- Appearance: Limbs appear normal.
- Associated findings: Hair loss, coldness, cyanosis, and/or thickened and malformed toenails.
Rest Pain:
- Symptoms: Severe ischemia leading to pain at rest, often requiring the leg to be in a dependent position.
- Appearance: Foot is bright red and cold in dependency.
- Associated findings: Atrophic, dry, and shiny skin due to severe ischemia.
17
Q
What is the significance of assessing collateral circulation in patients with peripheral arterial disease?
A
Assessing collateral circulation is significant because it helps evaluate the adequacy of blood flow to the limbs affected by peripheral arterial disease (PAD).
- Procedure:
1. Elevate the limb at a 45-degree angle for 2 minutes; normal response should not produce pallor.
2. Observe the time for filling of the foot veins and flushing of the feet when the legs are dependent.
- Expected Findings:
- Veins should fill within 20 seconds and feet should flush immediately in a warm environment.
- Inadequate Findings:
- If pallor occurs or if filling takes longer than 30 seconds, it indicates compromised blood flow, which may lead to rest pain, ulcers, or gangrene.
18
Q
What are the common cutaneous findings associated with severe ischemia in peripheral arterial disease?
A
Common cutaneous findings associated with severe ischemia in peripheral arterial disease include:
- Atrophic skin: Skin appears thin and shiny.
- Dryness: Lack of moisture in the skin.
- Ulcerations: Most often starting at the tips of the toes or heel, with irregular borders and a pale base.
- Gangrene: One or more toes may become black, dry, and mummified.
- Signs of infection: Purulent discharge or decay (wet gangrene) and surrounding tissue erythema and swelling.
19
Q
What are the key clinical features of acute limb ischemia as presented in the ‘5 Ps’ pentad?
A
The key clinical features of acute limb ischemia include:
1. Severe pain - usually persistent at rest
2. Pallor - pale appearance of the limb
3. Pulselessness - absence of pulse in the affected limb
4. Paresthesias - abnormal sensations such as tingling
5. Paralysis - loss of movement in the affected limb
6. Poikilothermia - cold extremity
7. Neurologic symptoms - indicates severe ischemia and need for emergent evaluation.
20
Q
How does intermittent claudication differ from rest pain in terms of clinical findings?
A
Intermittent Claudication:
- Limbs appear normal
- Associated clinical findings include:
- Hair loss
- Coldness
- Cyanosis
- Thickened and malformed toenails
Rest Pain:
- Foot appears bright red and cold in dependency
- Severe ischemia may present with:
- Atrophic, dry, and shiny skin
The key difference lies in the appearance of the limb and associated symptoms during activity versus at rest.
21
Q
What is the significance of assessing collateral circulation in patients with PAD?
A
Assessing collateral circulation in patients with PAD is significant because it helps evaluate the adequacy of blood flow to the affected limbs. The assessment can be performed through simple bedside examination:
1. Elevate the limb at a 45-degree angle for 2 minutes; normal response should not produce pallor.
2. Measure the time for filling of the foot veins and flushing of the feet when the legs are dependent.
- Normal: veins fill within 20 seconds and feet flush immediately.
- Inadequate: >30 seconds, indicating potential for rest pain, ulcers, or gangrene.
This evaluation is crucial for determining the severity of PAD and guiding treatment decisions.
22
Q
What are the common cutaneous findings associated with severe arterial obstruction in PAD?
A
Common cutaneous findings associated with severe arterial obstruction in PAD include:
- Ulcerations:
- Most often start at the tips of the toes or on the heel of the foot
- Extremely painful, except in cases of diabetic neuropathy
- Irregular borders and a pale base
- Gangrene may occur, with toes becoming black, dry, and mummified
- Signs of infection may include purulent discharge and surrounding tissue erythema and swelling
These findings indicate significant ischemia and require prompt medical attention.
23
Q
What are the major complications associated with progressive severe ischemia in PAD?
A
- Limb loss due to progressive severe ischemia or superimposed infection
- High risk of infection and slow or absent wound healing
- Urgent need for revascularization to avoid amputation
- Superimposed infections require aggressive treatment with antibiotics and wound care; can present as a medical emergency
24
Q
What are the key atherosclerotic risk factors for developing PAD?
A
1) Diabetes mellitus - develops at an earlier age, more severe and progressive
2) Hypertension
3) Hyperlipidemia - present in 50% of cases
4) Smoking
5) Family history of vascular disease
6) Obesity
- Most significant risk factors are diabetes mellitus and smoking, associated with a doubling of relative risk.
25
What is the significance of the ankle-brachial index (ABI) in diagnosing PAD?
- The ABI is the recommended diagnostic test to assess PAD.
- It is the ratio of the blood pressure at the ankle to the blood pressure in the upper arm.
- Normal ABI: 1.00 - 1.40; Abnormal: ≤ 0.90; Borderline: 0.91 - 0.99.
- Falsely elevated ABIs (greater than 1.4) indicate heavily calcified or noncompressible vessels, often seen in patients with diabetes or advanced age.
- An exercise ABI is recommended if the ABI is borderline or normal despite claudication symptoms.
26
What are the pathological findings associated with PAD?
- **Morphologically diverse** findings in large- and medium-sized arteries.
- **Focal accumulation** of lipids and lipoprotein, mucopolysaccharides, collagen, smooth muscle cells, macrophages, and calcium deposits.
- **Localized areas** of intimal thickening due to smooth muscle cell proliferation and lipid-laden macrophages.
- **Atrophic media** with thin strands of smooth muscle, lipid pools, collagen tissue, and calcium deposits.
- **Enlarging plaques** may encroach on the lumen and can ulcerate, leading to thrombi formation and occlusion of the narrowed arterial lumen.
27
What are the major direct complications associated with severe ischemia in PAD?
Limb loss and superimposed infection.
28
What is the significance of rest pain or tissue loss in PAD patients?
It indicates a high risk of infection and slow or absent wound healing, necessitating urgent revascularization to avoid amputation.
29
What are some common atherosclerotic risk factors for developing PAD?
Diabetes mellitus, hypertension, hyperlipidemia, smoking, family history of vascular disease, and obesity.
30
How does diabetes mellitus affect the severity and progression of PAD?
Diabetes mellitus leads to earlier onset, more severe and progressive disease, with less aortoiliac involvement and more extensive disease of the run-off vessels below the knees.
31
What is the normal range for the ankle-brachial index (ABI)?
Normal ABI is between 1.00 and 1.40.
32
What does an ABI of 0.90 or less indicate?
It indicates abnormal blood flow and potential PAD.
33
What is the purpose of performing an exercise ABI?
To assess the need for revascularization and determine wound healing when the resting ABI is borderline or normal despite symptoms of claudication.
34
What are some diagnostic methods used to evaluate PAD?
Segmental pressures, Doppler waveform analysis, pulse volume recordings, ABI with duplex ultrasonography, and magnetic resonance angiography.
35
What happens to blood flow in the affected limb during exercise in PAD patients?
Blood flow cannot maximally increase due to fixed proximal arterial stenoses, leading to claudication symptoms.
36
What is the role of collateral blood vessels in PAD?
Collateral blood vessels develop to maintain tissue perfusion, but blood pressure distal to occlusions is decreased due to high resistance and limited flow.
37
A patient with PAD has a normal resting ABI but experiences claudication symptoms. What diagnostic test should be performed next?
An exercise ABI should be performed to unmask the stenosis and assess post-exercise blood flow.
38
A patient with PAD has a resting blood flow similar to a healthy person but experiences claudication during exercise. Explain the pathophysiology behind this.
During exercise, blood flow cannot maximally increase in muscle tissue due to fixed proximal arterial stenoses. When metabolic demands exceed blood flow, claudication symptoms occur.
39
What are the two most significant risk factors for PAD?
The two most significant risk factors are diabetes mellitus and smoking.
40
A patient with PAD has a falsely elevated ABI (>1.4). What is the next diagnostic step?
Perform a toe-brachial index, as smaller vessels are rarely affected by calcification.
41
A patient with PAD has a history of smoking and presents with rest pain. What is the next step in management?
Urgent revascularization is needed to avoid limb loss.
42
A patient with PAD has a normal ABI but symptoms suggestive of claudication. What is the next diagnostic step?
An exercise ABI is recommended to assess for post-exercise blood flow limitations.
43
A patient with PAD has a history of diabetes and presents with a non-healing ulcer. What is the likely cause?
The non-healing ulcer is likely due to impaired wound healing associated with diabetes and PAD.
44
A patient with PAD has a history of coronary artery disease. What is the relationship between these conditions?
PAD and coronary artery disease share similar atherosclerotic risk factors, such as diabetes, hypertension, and smoking.
45
A patient with PAD has a falsely elevated ABI due to heavily calcified vessels. What is the alternative diagnostic method?
A toe-brachial index should be performed, as smaller vessels are less likely to be calcified.
46
What are the complications of untreated PAD?
Complications include limb loss from severe ischemia or superimposed infection, and increased risk of cardiovascular events like myocardial infarction or stroke.
47
What are the major complications associated with progressive severe ischemia in patients with PAD, and how should they be managed?
- Major complications include:
- Limb loss due to progressive severe ischemia or superimposed infection.
- Increased risk of infection and slow or absent wound healing in patients with rest pain or tissue loss.
48
What are the major complications associated with progressive severe ischemia in patients with PAD?
- Limb loss due to progressive severe ischemia or superimposed infection.
- Increased risk of infection and slow or absent wound healing in patients with rest pain or tissue loss.
49
How should major complications of PAD be managed?
Management strategies include:
1. Urgent need for revascularization to avoid amputation.
2. Aggressive treatment of superimposed infections with antibiotics.
3. Wound debridement and local foot care are essential, especially if the infection is rapidly progressive.
50
How does diabetes mellitus influence the severity and progression of PAD?
Diabetes mellitus leads to earlier onset, more severe and progressive forms of PAD, and less involvement of aortoiliac regions with more extensive disease in the run-off vessels below the knees.
51
What are other risk factors for PAD?
- Hypertension
- Hyperlipidemia (50% prevalence)
- Smoking
- Family history of vascular disease
- Obesity
52
What diagnostic tests are recommended for assessing PAD?
The ankle-brachial index (ABI) is the recommended diagnostic test for PAD, measuring the ratio of blood pressure at the ankle to blood pressure in the upper arm.
53
What are the normal and abnormal ranges for ABI?
Normal ABI ranges from 1.00 to 1.40; abnormal is ≤ 0.90; borderline is 0.91 - 0.99.
54
What physiological changes occur in blood flow during exercise in patients with PAD?
During exercise, blood flow cannot maximally increase in muscle tissue due to fixed proximal arterial stenoses, leading to claudication symptoms.
55
What are the major direct complications associated with progressive severe ischemia in patients with PAD?
The major direct complications include limb loss due to progressive severe ischemia, superimposed infection, and rest pain or tissue loss.
56
What is the significance of the ankle-brachial index (ABI) in diagnosing PAD?
The ABI helps assess PAD by comparing blood pressure at the ankle to that in the arm, indicating the need for revascularization and assessing wound healing potential.
57
What are the implications of exercise on blood flow in patients with PAD?
Resting blood flow may be similar to healthy individuals, but during exercise, blood flow cannot maximally increase, leading to claudication symptoms.
58
What are the typical diagnostic criteria for intermittent claudication?
- Typical history of intermittent claudication
- Palpation for diminished or absent pulses in the limbs
- Ankle-Brachial Index (ABI) is usually diminished.
59
What are the characteristics of diabetic neuropathic foot ulcers?
- Location: heel, toes, or shin
- Pulses: normal
- Pain: painless (neurotrophic)
- Cause: repetitive trauma
- Features: over pressure points with a surrounding callus.
60
What is the prognosis for patients with intermittent claudication?
60% to 90% remain stable over 5-9 years, with spontaneous improvement in symptoms likely.
61
What are the management goals for patients with PAD?
Goals include halting disease progression and alleviating symptoms through cessation of smoking, optimization of risk factors, and an exercise program.
62
What are the risk factors associated with increased amputation rates in PAD patients?
- Ongoing smoking
- Diabetes mellitus
- Advanced atherosclerosis.
63
What is the typical history used to diagnose intermittent claudication?
A typical history of intermittent claudication and palpation for diminished or absent pulses in the limbs.
64
What does a diminished ABI indicate in the context of arterial disease?
A diminished ABI indicates limited blood flow due to arterial obstructive disease.
65
What is the most feared consequence of severe limb-threatening ischemia?
Amputation.
66
What factors increase the amputation rate in patients with diabetes mellitus?
Diabetes mellitus increases the amputation rate fourfold.
67
What is the goal of medical management for PAD?
To halt the progression of the disease and alleviate the symptoms.
68
What lifestyle change is recommended to halt the progression of PAD?
Cessation of smoking.
69
What is often the treatment of choice for intermittent claudication?
An exercise program.
70
What is a common characteristic of neurogenic claudication?
Leg pain may occur in the erect position without exercise and is relieved by leaning forward or sitting.
71
What is the most feared complication of PAD, and how can it be prevented?
The most feared complication is severe limb-threatening ischemia leading to amputation. Prevention includes smoking cessation, controlling diabetes and hypertension, and treating hyperlipidemia.
72
What are the key differences between diabetic neuropathic foot ulcers and arterial limb ulcers?
| Type of Ulcer | Tenderness | Surrounding Callus |
|---------------|------------|--------------------|
| Diabetic Neuropathic Foot Ulcers | Normal | Present |
| Arterial Limb Ulcers | Exquisitely tender | Absent |
73
What are the clinical implications of neurogenic claudication compared to intermittent claudication?
- Neurogenic Claudication: Symptoms may be relieved by leaning forward or sitting, confirmed by MRI or CT scan.
- Intermittent Claudication: Symptoms occur with exercise and improve with rest, diagnosed through ABI measurement.
74
What management strategies are recommended to halt the progression of PAD?
1. Cessation of Smoking
2. Optimization of Risk Factors
3. Exercise Program.
75
How does the prognosis of intermittent claudication differ from severe limb-threatening ischemia?
- Intermittent Claudication: Generally benign; 60% to 90% remain stable.
- Severe Limb-Threatening Ischemia: High risk of amputation.
76
What is the recommended exercise regimen for patients with intermittent claudication?
Patients should exercise to the threshold of tolerable pain, briefly rest, and then continue exercising for a total duration of 30 to 60 minutes a day, 3 or more times a week.
77
What are the two agents approved in the US for the treatment of intermittent claudication?
1. Cilostazol: A phosphodiesterase inhibitor that improves symptoms and increases walking distance.
2. Pentoxifylline: Affects red cell deformability and blood viscosity.
78
What are the key components of prevention for patients with PAD?
Key prevention strategies include quitting smoking, controlling hypertension and diabetes, managing hyperlipidemias, statin therapy, and antiplatelet therapy.
79
What is the clinical significance of atheromatous embolism in patients with severe atherosclerotic disease?
Atheromatous embolism is associated with a significantly increased incidence of deaths following cardiac surgery or angiography.
80
What is the typical age range associated with atheromatous embolism?
66 to 72 years.
81
What is the primary etiology of atheromatous embolism?
Occlusion of small arteries and arterioles by atheromatous debris (cholesterol crystals).
82
What is the primary benefit of regular exercise for patients with PAD?
It conditions the muscles to work more efficiently and improves blood flow.
83
What is the contraindication for Cilostazol?
Congestive Heart Failure (CHF).
84
What is the significance of keeping feet warm, clean, and dry in PAD management?
To prevent ischemic tissue from being susceptible to burning and frostbite.
85
What is the role of antiplatelet therapy in PAD management?
To reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.
86
What lifestyle change is most consistently associated with the progression of PAD?
Tobacco smoking.
87
What is the incidence of atheromatous embolism in patients with severe atherosclerotic disease?
It increases dramatically in the presence of severe atherosclerotic disease.
88
What is the recommended exercise duration for patients with intermittent claudication?
30 to 60 minutes a day, 3 or more times a week.
89
A patient with PAD has dry gangrene of the toes. What is the recommended management approach?
Allow the gangrene to spontaneously demarcate, keep edges open, observe for infection, and provide pain medication as needed.
90
What are the two US-approved agents for the treatment of intermittent claudication and their primary effects?
1. **Cilostazol**: A phosphodiesterase inhibitor with anti-platelet and vasodilatory properties that improves symptoms and increases walking distance by 40% to 60% after 12 to 24 weeks of therapy. Side effects include GI symptoms and headaches, with contraindication in CHF.
2. **Pentoxifylline**: Affects red cell deformability and blood viscosity, serving as a second-line alternative therapy that improves pain-free and maximal walking distance.
91
What is the recommended management approach for a patient with PAD who has dry gangrene of the toes?
Allow the gangrene to spontaneously demarcate, keep edges open, observe for infection, and provide pain medication as needed.
92
What additional therapy should a patient with PAD and a target LDL of <70 mg/dL be on to prevent cardiovascular events?
They should be on a statin to prevent the progression of PAD and reduce the risk of myocardial infarction and stroke.
93
What is the role of antiplatelet therapy in PAD management?
Antiplatelet therapy reduces the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.
94
What surgical options are available for a patient with PAD who has ischemic rest pain and ulcers?
Surgical bypass techniques or endovascular interventions like angioplasty or stenting may be considered.
95
What is the most consistent adverse risk factor for the progression of PAD?
The most consistent adverse risk factor is continued smoking.
96
What is the role of cilostazol in the management of PAD?
Cilostazol improves symptoms and increases walking distance by 40-60% after 12-24 weeks of therapy.
97
What is the recommended exercise regimen for patients with intermittent claudication to improve their symptoms?
Patients should exercise to the threshold of tolerable pain, briefly rest, and then exercise again for a total duration of 30 to 60 minutes a day, exceeding their normal activity, 3 or more times a week. This should be performed in one session, with walking being the preferred modality.
98
What are the key preventive measures for patients with Peripheral Arterial Disease (PAD)?
Key preventive measures include:
- **Quitting smoking**: Most consistent adverse risk factor associated with disease progression; quitting slows PAD progression and reduces amputation rates.
- **Controlling hypertension and diabetes mellitus**: Essential for managing PAD.
- **Managing hyperlipidemia**: Target LDL of <100 mg/dL (or <70 mg/dL with multiple risk factors).
- **Statin therapy**: Recommended to prevent progression of PAD and reduce myocardial infarction and stroke risk.
- **Antiplatelet therapy**: To reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.
99
What is the clinical significance of atheromatous embolism in patients with severe atherosclerotic disease?
Atheromatous embolism is significant as it can lead to occlusion of small arteries and arterioles, resulting in serious complications. The incidence dramatically increases in the presence of severe atherosclerotic disease, contributing to over 20% of deaths following cardiac surgery or angiography.
100
What are the recommended management strategies for patients with dry gangrene of the digits or lower limbs?
Management strategies for dry gangrene include:
1. Allow spontaneous demarcation of the affected area.
2. Avoid soaking or using ointments, as they are unnecessary.
3. Keep the edges of the gangrenous area open if possible.
4. Monitor frequently for signs of infection.
5. Provide pain medication as necessary for 2 to 3 months.
6. For infected (wet) gangrenous areas, active debridement and appropriate antibiotics may be necessary.
101
What is the clinical picture associated with atheromatous embolism?
The clinical picture includes impaired perfusion of the skin and muscle due to small vessel occlusion, which can affect nearly any organ of the body, leading to ischemia, infarction, and necrosis.
102
What are the major risk factors for atheromatous embolism?
Major risk factors include:
- Atherosclerotic disease of the thoracic or abdominal aorta
- More extensive atheroma burden (thickness above 4 mm)
- Unfavorable plaque features, such as protruding mobile plaque
- Coexistent vascular diseases, including coronary artery disease and PAD
- Older age (over 60 years)
103
What are common cutaneous lesions associated with atheromatous embolism?
Common cutaneous lesions include:
- Cyanosis
- Necrosis
- Gangrene
- Ulcerations
- Fissures
- 'Blue toe syndrome' (tender, cool, blue, or purple toes with normal pulses)
- Livedo racemosa (50% prevalence)
- Erythematous lesions on the lateral aspect of the foot and calcaneal region.
104
What complications can arise from renal atheroembolic disease?
Complications include glomerular sclerosis, tubular atrophy, interstitial fibrosis, new onset of hypertension or overt renal failure, gross hematuria or frank renal infarction (rare), and renal failure, which has a high mortality rate.
105
What laboratory tests are used to diagnose atheromatous embolism?
Laboratory tests include nonspecific tests depending on the organ involved, systemic inflammatory response indicators (elevated ESR, thrombocytopenia, hypocomplementemia, leukocytosis, and anemia), renal involvement tests (azotemia, proteinuria, microscopic hematuria, eosinophilia), and GI tract involvement tests (anemia and blood in stool).
106
What is the primary cause of ischemia, infarction, and necrosis in the context of atheroembolism?
Dislodgement of atherosclerotic plaque followed by a foreign-body inflammatory cascade.
107
What are the major risk factors for atheroembolism?
Atherosclerotic disease of the thoracic or abdominal aorta, older age, and unfavorable plaque features.
108
What are common clinical manifestations of atheroembolism?
Impaired perfusion of the skin and muscle, which can lead to small vessel occlusion.
109
What is 'blue toe syndrome' and what does it indicate?
'Blue toe syndrome' includes tender, cool, blue, or purple toes with normal pulses, indicating tissue or digital ischemia.
110
What are the common diagnostic tests for atheroembolic disease?
Common diagnostic tests include contrast angiography, computed tomographic angiography, and magnetic resonance angiography.
111
What are the systemic inflammatory response indicators in atheroembolic disease?
Increased ESR, thrombocytopenia, hypocomplementemia, leukocytosis, and anemia.
112
What are the common cutaneous lesions associated with atheroembolism?
Cyanosis, necrosis, gangrene, ulcerations, and fissures.
113
What is the significance of transient eosinophilia in renal involvement of atheroembolic disease?
It occurs in 80% of renal involvement cases, indicating an inflammatory response.
114
What are the potential complications of atheroembolism affecting the CNS?
Transient ischemic attacks, stroke, and paralysis.
115
What is the pathophysiology behind renal failure in atheromatous embolism?
Renal failure occurs due to the showering of emboli to renal parenchymal branch vessels, leading to glomerular sclerosis, tubular atrophy, and interstitial fibrosis.
116
What are the dermatologic manifestations of atheromatous embolism?
Manifestations include cyanosis, necrosis, gangrene, ulcerations, fissures, petechiae, ecchymosis, purpura, and splinter hemorrhages.
117
What are the potential complications associated with renal atheroembolic disease following an invasive procedure?
Complications may include new onset of hypertension or overt renal failure, gross hematuria or frank renal infarction (rare), renal failure associated with high mortality, and intense inflammatory process leading to glomerular sclerosis, tubular atrophy, and interstitial fibrosis.
118
How does the clinical presentation of cutaneous lesions in atheroembolism differ from other ischemic conditions?
In atheroembolism, cutaneous lesions often present as cyanosis and necrosis of digits, gangrene and ulcerations, fissures and blue toe syndrome, erythematous lesions on the lateral aspect of the foot and calcaneal region, and hemorrhagic manifestations such as petechiae, ecchymosis, purpura, and splinter hemorrhages.
119
What are the systemic complications that can arise from embolism originating from the ascending aorta?
Systemic complications from embolism originating from the ascending aorta may include transient ischemic attacks, strokes, and retinal manifestations.
120
What are the key laboratory findings indicative of renal involvement in atheroembolic disease?
Key laboratory findings may include azotemia, proteinuria, microscopic hematuria, eosinophilia, and transient eosinophilia observed in 80% of renal involvement cases.
121
What are the major risk factors for atheromatous embolism, particularly related to the thoracic or abdominal aorta?
Major risk factors include atherosclerotic disease of the thoracic or abdominal aorta, older age (older than 60 years), more extensive atheroma burden, unfavorable plaque features, and coexistent vascular diseases.
122
What is the significance of transthoracic and transesophageal echocardiography in diagnosing cardiac sources of emboli?
Transthoracic echocardiography is used to evaluate for a cardiac source, while transesophageal echocardiography is more definitive and can also assess the thoracic aorta for plaque.
123
What are the key characteristics of cholesterol embolization diagnosis?
Diagnosis requires demonstration of cholesterol crystals that appear as empty clefts due to solubility in solvents. Skin, muscle, or renal biopsies show elongated, needle-shaped clefts in small arterial vessels, with inflammatory infiltrates and perivascular fibrosis.
124
What are the common clinical features that suggest a diagnosis of atheromatous emboli?
Common features include blue or ulcerated painful digits, livedo racemosa, petechiae, and tender calf muscles in the presence of normal pulses.
125
What is the prognosis for patients with atheromatous emboli?
The prognosis is generally poor due to severe underlying atherosclerosis, with a 20% to 30% mortality rate within one year.
126
What are the mainstays of therapy for managing atheromatous emboli?
Mainstays of therapy include early recognition to minimize end-organ damage, preventing further ischemic insult, supportive care, and removal of the atheromatous source through surgical or endovascular procedures.
127
What preventive measures are recommended for high-risk patients to avoid atherosclerotic plaque development?
Preventive measures include increasing awareness, targeting high-risk patients, avoiding unnecessary invasive procedures, using soft-tipped guidewires during angiography, and employing protective devices like filters and balloons.
128
What is Thromboangiitis Obliterans (Buerger Disease) and its association with tobacco use?
Thromboangiitis Obliterans is a rare, progressive inflammatory disease that predominantly affects small- and medium-sized arteries of the extremities and is strongly associated with tobacco use.
129
What is the epidemiology of Thromboangiitis Obliterans?
The prevalence is greatest in Mediterranean countries, the Middle East, and Asia, with a lower prevalence in northern Europe. The male-to-female ratio is approximately 3:1.
130
What is the role of transthoracic echocardiography in diagnosing cardiac sources?
It evaluates for a cardiac source.
131
What is the significance of skin, muscle, or renal biopsies in cholesterol embolization diagnosis?
They help demonstrate cholesterol crystals and assess the extent of damage.
132
What are the common clinical features suggesting atheromatous emboli?
Blue or ulcerated painful digits, livedo racemosa, petechiae, and tender calf muscles with normal pulses.
133
What is the prognosis for patients with severe underlying atherosclerosis?
Generally poor, with a mortality rate of 20% to 30% for 1-year mortality.
134
What are the mainstays of therapy for managing atheromatous emboli?
Preventing further ischemic insult and supportive care.
135
What is the recommended approach for primary prevention in high-risk patients?
Targeted strategies to avoid the development of atherosclerotic plaque.
136
What is the association between thromboangiitis obliterans and tobacco use?
It is strongly associated with the use of tobacco products.
137
What is the typical demographic affected by thromboangiitis obliterans?
Predominantly affects men aged 20 to 40 years.
138
What is the prevalence of thromboangiitis obliterans in Mediterranean countries?
It has the greatest prevalence in Mediterranean countries, the Middle East, and Asia.
139
What is the significance of early recognition in managing atheromatous emboli?
It is essential to minimize end-organ damage and improve clinical outcomes.
140
What is the recommended diagnostic test to confirm livedo racemosa in atheromatous embolism?
A skin biopsy from areas with livedo racemosa can confirm the diagnosis by demonstrating cholesterol crystals.
141
What is the primary management strategy for atheromatous embolism?
Management includes preventing further ischemic insult, supportive care, and removal of the atheromatous source through surgical bypass or endarterectomy.
142
What are the key diagnostic methods for cholesterol embolization and their sensitivities?
Key diagnostic methods include transthoracic echocardiography, transesophageal echocardiography, and skin, muscle, or renal biopsies.
143
What are the key diagnostic methods for cholesterol embolization and their sensitivities?
Key diagnostic methods include:
- **Transthoracic echocardiography**: evaluates for a cardiac source.
- **Transesophageal echocardiography**: more definitive, assesses thoracic aorta for plaque.
- **Skin, muscle, or renal biopsies**:
- Muscle biopsy: most sensitive test (>95%), but technically difficult and painful.
- Skin biopsy: sensitivity 40%-90%, best yield from areas of suspected emboli.
144
What are the clinical features that suggest a diagnosis of atheromatous emboli?
Clinical features suggesting atheromatous emboli include:
- **Blue or ulcerated painful digits**
- **Livedo racemosa**
- **Petechiae**
- **Tender calf muscles** in the presence of normal pulses
These features often indicate a high index of suspicion in patients with a history of atherosclerotic disease.
145
What is the prognosis for patients with atheromatous emboli and what factors influence it?
Prognosis for patients with atheromatous emboli is generally poor due to severe underlying atherosclerosis. Key factors influencing prognosis include:
- **Organ system affected**: Mortality is 20% to 30% for 1-year mortality.
- **Location of emboli**: Suprarenal location has the poorest outcomes.
- **Complications**: Systemic complications, particularly renal failure or stroke, significantly worsen prognosis.
146
What are the mainstays of therapy for managing atheromatous emboli?
Mainstays of therapy for managing atheromatous emboli include:
1. **Early recognition**: Essential to minimize end-organ damage.
2. **Preventing further ischemic insult**.
3. **Supportive care**.
4. **Removal of the atheromatous source**: Surgical bypasses or endarterectomy.
5. **Medical therapies**:
- Antiplatelet agents (e.g., aspirin, dipyridamole).
- Antithrombotic therapy (e.g., subcutaneous heparin).
- Statins for plaque stabilization.
- Limited evidence for iloprost and cilostazol.
147
What preventive measures are recommended for high-risk patients to avoid atheromatous emboli?
Preventive measures for high-risk patients include:
- **Increased awareness** of atherosclerotic plaque development.
- **Primary prevention** strategies targeting high-risk individuals.
- **Avoiding unnecessary invasive procedures** once atherosclerosis develops.
- **Cautious techniques during angiography**: Use of soft-tipped guidewires and flexible catheters.
- **Use of protective devices**: Filters, baskets, and balloon occlusion during procedures.
148
What are the most common initial complaints in patients with thromboangiitis obliterans?
- Claudication of the foot or lower calf
- Digital cyanosis or gangrene
- Rest pain
149
What are the typical cutaneous findings associated with thromboangiitis obliterans?
- Ulcers of the toes or fingers
- Lower extremities involvement is most common
- >1/3 of patients may have upper extremity involvement
- Superficial thrombophlebitis, often migratory
- Cold sensitivity or classical Raynaud phenomenon
150
What is the primary management strategy for thromboangiitis obliterans?
- Smoking cessation is crucial for dramatic improvement.
- Avoidance of smokeless tobacco and nicotine-containing patches is also necessary.
151
What are the key diagnostic criteria for thromboangiitis obliterans?
- Clinical presentation and arteriography findings are essential.
- Arteriography typically shows corkscrew-shaped collaterals.
- Exclusion of arteriosclerosis and other occlusive vasculopathies is crucial.
152
What preventive strategies are recommended for patients with thromboangiitis obliterans?
- Absolute discontinuation of tobacco is the only proven strategy to prevent disease progression.
- Use well-fitting protective footwear to prevent foot trauma.
- Avoidance of cold environments and drugs that lead to vasoconstriction.
153
What is a characteristic finding in the arteriography of thromboangiitis obliterans?
Corkscrew-shaped collaterals.
154
What is the role of IV prostacyclin analog, iloprost, in the management of thromboangiitis obliterans?
It improves ulcer healing and eliminates rest pain, as compared to aspirin.
155
What is the significance of smoking in the etiology of thromboangiitis obliterans?
It is almost exclusively found in smokers and often abates with cessation of tobacco smoking.
156
What are the common findings in the hands and feet of patients with thromboangiitis obliterans?
Cold and mildly edematous, with cyanotic, ulcerated, or gangrenous and very painful digits.
157
What is the typical histopathologic finding in thromboangiitis obliterans?
Inflammatory thrombus infiltrated with polymorphonuclear leukocytes and multinucleated giant cells.
158
A 35-year-old smoker presents with claudication and migratory superficial thrombophlebitis. What is the most likely diagnosis?
The most likely diagnosis is thromboangiitis obliterans (Buerger disease).
159
What are the three most common initial complaints of thromboangiitis obliterans?
The three most common complaints are claudication of the foot or lower calf, digital cyanosis or gangrene, and rest pain.
160
What is the only proven strategy to prevent the progression of thromboangiitis obliterans?
The only proven strategy is absolute discontinuation of tobacco use.
161
What are the typical arteriography findings in thromboangiitis obliterans?
Arteriography typically shows corkscrew-shaped collaterals, which are not pathognomonic but are characteristic.
162
What are the histopathologic findings in thromboangiitis obliterans?
Findings include inflammatory thrombus infiltrated with polymorphonuclear leukocytes and multinucleated giant cells.
163
What are the preventive strategies for complications in thromboangiitis obliterans?
Strategies include using well-fitting protective footwear, avoiding cold environments, and avoiding vasoconstrictive drugs.
164
What is the most classic symptom of Peripheral Arterial Disease (PAD)?
The most classic symptom of PAD is **claudication**.
165
What is the most common muscle group involved in PAD and which artery is most commonly affected?
The most common muscle group involved is the **calf muscles**, with the most common artery being the **popliteal artery**.
166
What are the components of the pentad of acute limb ischemia?
The pentad of acute limb ischemia includes:
1. **Pain**
2. **Pallor**
3. **Pulselessness**
4. **Paresthesia**
5. **Paralysis**
167
What is the hallmark noncutaneous finding in PAD?
The hallmark noncutaneous finding in PAD is **intermittent claudication**.
168
What are the most significant risk factors for PAD?
The most significant risk factors for PAD are **smoking** and **diabetes**.
169
How does blood flow in resting conditions compare to during exercise in PAD?
Blood flow in resting conditions is **reduced**; in exercise, it increases to **4-fold**.
170
What are the classifications of Ankle-Brachial Index (ABI)?
ABI classifications are:
- Normal: **1.0 - 1.4**
- Abnormal: **<0.9**
- Borderline: **0.91 - 0.99**
- Heavy calcification of vessels: **>1.4**
171
What is the most feared consequence of PAD?
The most feared consequence of PAD is **amputation**.
172
What is the treatment of choice for intermittent claudication?
The treatment of choice for intermittent claudication is **supervised exercise therapy**.
173
What are the two US approved agents for intermittent claudication?
The two US approved agents for intermittent claudication are **cilostazol** and **pentoxifylline**.
174
What is the most consistent adverse risk factor for progression of PAD?
The most consistent adverse risk factor for progression of the disease is **smoking**.
175
What is the major risk factor in atheromatous embolism?
The major risk factor in atheromatous embolism is **atherosclerosis**.
176
What does the term 'blue toe syndrome' refer to?
Blue toe syndrome includes **tender, cool, blue, or purple toes** with normal pulses.
177
What is a specific but insensitive fundoscopic finding associated with a cholesterol embolus?
A specific but insensitive fundoscopic finding is **Hollenhorst plaque**.
178
What are the common organ systems complicated by atheromatous emboli?
The common organ systems complicated by atheromatous emboli are **kidneys**, **brain**, and **skin**.
179
What does the presence of blue or ulcerated painful digits suggest in a patient?
The presence of blue or ulcerated painful digits suggests the diagnosis of **thromboangiitis obliterans**.
180
What is the location associated with the poorest outcomes in atheromatous emboli?
The poorest outcomes in atheromatous emboli have a **distal** location.
181
How can the source of an emboli be eliminated?
The source of the emboli can be eliminated through **surgery** or **medical management**.
182
What are the three most common initial complaints of thromboangiitis obliterans?
The three most common initial complaints of thromboangiitis obliterans are:
1. **Claudication**
2. **Rest pain**
3. **Ulceration**
183
In thromboangiitis obliterans, what is the status of the distal pulses?
In thromboangiitis obliterans, the distal pulses are **absent**.
184
What HLA types are increased in thromboangiitis obliterans?
HLA-**A**, HLA-**B**, and HLA-**DR** are increased in thromboangiitis obliterans.
185
What are the typical arteriography findings in thromboangiitis obliterans?
Typical arteriography findings in thromboangiitis obliterans are **segmental occlusions** and **string of beads appearance**.
186
What is the first line therapy for thromboangiitis obliterans?
The first line therapy for thromboangiitis obliterans includes:
Improve blood flow:
1. **Vasodilators**
2. **Surgical revascularization**
Symptom relief:
1. **Analgesics**
2. **Smoking cessation**
187
What is the only strategy proven to prevent the progression of thromboangiitis obliterans?
The only strategy proven to prevent the progression of thromboangiitis obliterans is **smoking cessation**.
188
What is the most classic symptom of PAD?
Intermittent claudication.
189
What is the most common muscle group involved in PAD?
The calf muscles.
190
What is the most common artery involved in PAD?
The superficial femoral artery.
191
What are the components of the pentad of acute limb ischemia?
Pain, pallor, pulselessness, paresthesia, and paralysis.
192
What is the hallmark noncutaneous finding in PAD?
Intermittent claudication.
193
What are the most significant risk factors for PAD?
Smoking and diabetes.
194
How does blood flow in resting conditions compare to exercise in PAD?
Blood flow is reduced in resting conditions; in exercise, it increases to 5-fold.
195
What does ABI stand for and what are its normal values?
Ankle-Brachial Index; normal=1.
196
What does ABI stand for and what are its normal values?
Ankle-Brachial Index; normal=1.0-1.4, abnormal=<0.9, borderline=0.91-0.99, heavy calcification of vessels=>1.4.
197
What is the most feared consequence of PAD?
Amputation.
198
What is the treatment of choice for intermittent claudication?
Supervised exercise therapy.
199
What are the two US approved agents for intermittent claudication?
Cilostazol and pentoxifylline.
200
What is the most consistent adverse risk factor for progression of PAD?
Smoking.
201
What is the major risk factor in atheromatous embolism?
Atrial fibrillation.
202
What does atheromatous embolism include?
Tender, cool, blue, or purple toes with normal pulses.
203
What is a specific but insensitive fundoscopic finding in atheromatous embolism?
Cholesterol embolus.
204
What are the common organ systems complicated by atheromatous emboli?
Kidneys, brain, and extremities.
205
What does the presence of blue or ulcerated painful digits suggest?
The diagnosis of thromboangiitis obliterans.
206
What is the location associated with the poorest outcomes in atheromatous emboli?
Distal location.
207
How can the source of the emboli be eliminated?
Through surgery or anticoagulation.
208
What are the three most common initial complaints of thromboangiitis obliterans?
Claudication, rest pain, and ulceration.
209
In thromboangiitis obliterans, what is the status of the distal pulses?
Absent.
210
What HLA types are increased in thromboangiitis obliterans?
HLA- A, HLA- B, and HLA- DR.
211
What are typical arteriography findings in thromboangiitis obliterans?
Segmental occlusions and collateral circulation.
212
What is the first line therapy for thromboangiitis obliterans?
Improve blood flow and symptom relief.
213
What is the only strategy proven to prevent the progression of thromboangiitis obliterans?
Smoking cessation.
214
What are the characteristic features of arterial ulcers compared to venous and neuropathic ulcers?
Arterial ulcers have irregular borders, a pale base, and are extremely painful. Venous ulcers are shallow with irregular edges and exudate. Neuropathic ulcers are painless with a surrounding callus.
215
What is the most classic symptom of Peripheral Arterial Disease (PAD)?
The most classic symptom of PAD is claudication.
216
What are the most significant risk factors for Peripheral Arterial Disease (PAD)?
The most significant risk factors for PAD are smoking and diabetes.
217
What is the hallmark noncutaneous finding in Peripheral Arterial Disease (PAD)?
The hallmark noncutaneous finding in PAD is rest pain.
218
What is the treatment of choice for intermittent claudication in patients with PAD?
The treatment of choice for intermittent claudication is supervised exercise therapy.
219
What are the two US approved agents for intermittent claudication?
The two US approved agents for intermittent claudication are cilostazol and pentoxifylline.
220
What are the three most common initial complaints of thromboangiitis obliterans?
The three most common initial complaints of thromboangiitis obliterans are: Claudication, Rest pain, Ulceration.
221
What is the most consistent adverse risk factor for the progression of atheromatous embolism?
The most consistent adverse risk factor for progression of the disease is hypertension.
222
What are the common organ systems complicated by atheromatous emboli?
The common organ systems complicated by atheromatous emboli are: Kidneys, Brain, Lungs.
223
What is the first line therapy for thromboangiitis obliterans to improve blood flow?
The first line therapy for thromboangiitis obliterans to improve blood flow includes: Smoking cessation, Exercise therapy.
224
What is the only strategy proven to prevent the progression of thromboangiitis obliterans?
The only strategy proven to prevent the progression of thromboangiitis obliterans is smoking cessation.
225
Which muscle group is most commonly involved in PAD and what is the most common artery affected?
The most common muscle group involved is the calf muscles, with the most common artery being the popliteal artery.
