148: Cutaneous Changes in Arterial, Venous, and Lymphatic Dysfunction Flashcards
What is the most classic symptom of obstructive peripheral arterial disease (PAD)?
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.
What are the common cutaneous findings associated with obstructive peripheral arterial disease?
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.
What are the hallmark noncutaneous findings in peripheral arterial disease (PAD)?
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.
What is the significance of the ‘5 Ps’ in acute limb ischemia?
The ‘5 Ps’ include severe pain, pallor, pulselessness, paresthesias, and paralysis, indicating critical limb ischemia.
What is a hallmark noncutaneous finding in PAD?
Decreased or absent pulses distal to the stenotic arterial segment.
What does the presence of ulcers in PAD typically indicate?
Ulcers most often start at the tips of the toes or on the heel of the foot and are extremely painful, indicating severe ischemia.
What is the epidemiological prevalence of PAD in individuals aged 65 and older?
Up to 20% of individuals older than age 65 are affected by PAD.
What is the expected resolution time for symptoms of intermittent claudication after rest?
Symptoms typically resolve within several minutes of rest.
What is the relationship between collateral circulation and PAD symptoms?
Inadequate collateral circulation can lead to cold extremities, rest pain, and skin breakdown, worsening PAD symptoms.
What is the clinical significance of the time taken for foot veins to fill in PAD assessment?
Veins should fill within 20 seconds; if it takes longer than 30 seconds, it indicates inadequate circulation and potential complications.
What are the common demographic characteristics of PAD patients?
PAD is more common in individuals aged 40 to 59 years, with a higher incidence in females rapidly after menopause.
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?
The most likely diagnosis is Peripheral Arterial Disease (PAD). The hallmark noncutaneous finding is decreased or absent pulses distal to the stenotic arterial segment.
What are the five components of the pentad of acute limb ischemia?
The pentad includes severe pain, pallor, pulselessness, paresthesias, and paralysis.
A patient with PAD has ulcerations on the tips of their toes. What are the characteristic features of these ulcers?
The ulcers have irregular borders, a pale base, and are extremely painful unless diabetic neuropathy is present.
What are the key clinical features of acute limb ischemia as defined by the ‘5 Ps’?
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.
How does intermittent claudication differ from rest pain in patients with peripheral arterial disease?
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.
What is the significance of assessing collateral circulation in patients with peripheral arterial disease?
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.
What are the common cutaneous findings associated with severe ischemia in peripheral arterial disease?
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.
What are the key clinical features of acute limb ischemia as presented in the ‘5 Ps’ pentad?
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.
How does intermittent claudication differ from rest pain in terms of clinical findings?
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.
What is the significance of assessing collateral circulation in patients with PAD?
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.
What are the common cutaneous findings associated with severe arterial obstruction in PAD?
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.
What are the major complications associated with progressive severe ischemia in PAD?
- 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
What are the key atherosclerotic risk factors for developing PAD?
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.
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.
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.
What are the major direct complications associated with severe ischemia in PAD?
Limb loss and superimposed infection.
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.
What are some common atherosclerotic risk factors for developing PAD?
Diabetes mellitus, hypertension, hyperlipidemia, smoking, family history of vascular disease, and obesity.
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.
What is the normal range for the ankle-brachial index (ABI)?
Normal ABI is between 1.00 and 1.40.
What does an ABI of 0.90 or less indicate?
It indicates abnormal blood flow and potential PAD.
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.
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.
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.
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.
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.
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.
What are the two most significant risk factors for PAD?
The two most significant risk factors are diabetes mellitus and smoking.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
What are other risk factors for PAD?
- Hypertension
- Hyperlipidemia (50% prevalence)
- Smoking
- Family history of vascular disease
- Obesity
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.
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.
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.
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.
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.
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.
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.
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.
What is the prognosis for patients with intermittent claudication?
60% to 90% remain stable over 5-9 years, with spontaneous improvement in symptoms likely.
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.
What are the risk factors associated with increased amputation rates in PAD patients?
- Ongoing smoking
- Diabetes mellitus
- Advanced atherosclerosis.
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.
What does a diminished ABI indicate in the context of arterial disease?
A diminished ABI indicates limited blood flow due to arterial obstructive disease.
What is the most feared consequence of severe limb-threatening ischemia?
Amputation.
What factors increase the amputation rate in patients with diabetes mellitus?
Diabetes mellitus increases the amputation rate fourfold.
What is the goal of medical management for PAD?
To halt the progression of the disease and alleviate the symptoms.
What lifestyle change is recommended to halt the progression of PAD?
Cessation of smoking.
What is often the treatment of choice for intermittent claudication?
An exercise program.
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.
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.
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 |
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.
What management strategies are recommended to halt the progression of PAD?
- Cessation of Smoking
- Optimization of Risk Factors
- Exercise Program.
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.
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.
What are the two agents approved in the US for the treatment of intermittent claudication?
- Cilostazol: A phosphodiesterase inhibitor that improves symptoms and increases walking distance.
- Pentoxifylline: Affects red cell deformability and blood viscosity.
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.
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.
What is the typical age range associated with atheromatous embolism?
66 to 72 years.
What is the primary etiology of atheromatous embolism?
Occlusion of small arteries and arterioles by atheromatous debris (cholesterol crystals).
What is the primary benefit of regular exercise for patients with PAD?
It conditions the muscles to work more efficiently and improves blood flow.
What is the contraindication for Cilostazol?
Congestive Heart Failure (CHF).
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.
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.
What lifestyle change is most consistently associated with the progression of PAD?
Tobacco smoking.
What is the incidence of atheromatous embolism in patients with severe atherosclerotic disease?
It increases dramatically in the presence of severe atherosclerotic disease.
What is the recommended exercise duration for patients with intermittent claudication?
30 to 60 minutes a day, 3 or more times a week.
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.
What are the two US-approved agents for the treatment of intermittent claudication and their primary effects?
- 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.
- Pentoxifylline: Affects red cell deformability and blood viscosity, serving as a second-line alternative therapy that improves pain-free and maximal walking distance.
