17- Peripheral Arterial Disease

Question 1

define PAD

Answer 1

stenosis of the aorta or arteries in the limbs

Question 2

leading cause of PAD in patients >40 yo

Answer 2

atherosclerosis

Question 3

what might be the cause of PAD in a young female pt.?

Answer 3

fibromuscular dysplasia

Question 4

does everyone with PAD know it?

Answer 4

nope

10-30% are symptomatic

Question 5

modifiable risk factors for atherosclerosis

Answer 5

• DM
• HTN
• Tobacco
• Obesity
• HLD
• CKD

Question 6

how is diabetes a risk factor for atherosclerosis

Answer 6

endothelial cell dysfunction and inflamamtion

Question 7

how is HTN a risk factor for atheroscleroiss?

Answer 7

increased shear stress = decreased NO, increased inflammation and endothelial remodeling

Question 8

how is tobacco exposure an atherosclerosis risk factor?

Answer 8

vasoconstriction and pro-inflammatory substances

Question 9

why is obesity a risk factor for atherosclerosis?

Answer 9

pro-inflammatory state

Question 10

the greatest risk factor for PAD

Answer 10

cigarette smoking

Question 11

non-modifiable risk factors for atherosclerosis

Answer 11

male
age
race (black)
family history

Question 12

leukocytes, C reactive prtn and monocytes correlate with…

serum bilirubin correlates with..

Answer 12

PAD is correlated with leukocytes, c-reactive prtn and monocytes (inflammatory disease)

serum bilirubin is associated with reduced PAD prevalence

Question 13

oxygen demand of skeletal muscle during effort exceeds the blood’s oxygen supply =

Answer 13

intermittent claudication

*cardinal symptom PAD

Question 14

flow through an artery is ______ related to perfusion pressure and _________ related to vascular resistance

Answer 14

Flow = pressure/resistance

direct
inversely

Question 15

which type of fibers are lost with partial axonal denervation in legs affected by PAD?

Answer 15

type II glycolytic fast-twitch fibers are lost

–> decreased muscle strenght and acapacity

Question 16

the hallmark of all diabetic complications is…

Answer 16

endothelial dysfunction

because chronic metabolic changes lead to vasoconstriction, chronic inflammation and tendency towards thrombosis

Question 17

_____ vasodilatory and ______ vasoconstrictive cytokines

Answer 17

decreased dilatory and increased constrictive

chronic metaboic change of DM leading to endothelial dysfunction

Question 18

____ coagulation factor production and _______ platelet aggregation

Answer 18

both increased

tendency toward thrombosis with endothelial dysfunction

Question 19

how is PAD caused by chronic kidney disease CKD different than that caused by other etiologies?

Answer 19

calcification is predominant

preferentially affects the MEDIA and not the intima

related to abnormal Ca-Ph metabolism, and metabolic bone disease

—> stenosis without evidence of plaque on angiography

Question 20

primary stie of involvement in symptomatic patients

Answer 20

femoral and popliteal arteries (80-90%)

Question 21

edinburgh claudication questioinnaire

Answer 21

pain in either calf with walking and whether the pain occurs at trest, while walking at an ordinary or hurried pace or on walking uphill

history should note walking distance, speed and incline that precipitate claudication

Question 22

Does the pain ever begin when standing or sitting still?

Answer 22

NO = IC

Question 23

do you get pain if you walk uphill or hurry?

Answer 23

YES = IC

Question 24

do you get pain if you walk at ordinary level pace?

Answer 24

YES = severe IC

Question 25

pain goes away when stand still?

Answer 25

YES = IC

Question 26

where does claudication typically occur?

Answer 26

calf muscle

Question 27

pain or paresthesias in foot or toes that worsens with leg elevation and improves with dependency

Answer 27

critical limb ischemia

Question 28

gold standard for diagnosis of PAD

Answer 28

contrast angiography

Question 29

segmental pressure measurements indicate stenosis if…

Answer 29

BP gradient > 20 mmHg between cuffs in LE or 10 in UE

Question 30

Normal ABI

Answer 30

1-1.4

abnormal when ankle is lower pressure (ABI

Question 31

the lower the ABI, the …

Answer 31

less distance and lower speed in walking (more severe disease)

Question 32

ABI > 1.4 …

Answer 32

calcified, non-compressible vasculature

Question 33

decrease __- or more in ABI after exercise in pt with claudication is diagnostic

Answer 33

25%

Question 34

pulse volume recording =

Answer 34

plethysmography

Question 35

which is a better treatment: supervised exercise program or pharmacologic therapy?

Answer 35

both are equally efficacious

Question 36

should elastic hose be used in patients with intermittent claudication?

Answer 36

NO should be avoided

Question 37

what type of medication should all symptomatic PAD pts be taking?

Answer 37

antiplatelet medications

EX: cilostazol or pentoxifylline

Question 38

when is endovascualr therapy not indicated?

Answer 38

if there is no pressure gradient across the stenosis

Question 39

six Ps of acute limb ischemia

Answer 39

paresthesia
pain
pallor
pulselessness
poikilothermia
paralysis

Question 40

_____ of patients with claudication progress to critical limb ischemia. _____ of patients with critical limb ischemia go on to require amputation

Answer 40

10%

20-30%

Question 41

atherosclerosis is a ________ disease with ____________ preference

Answer 41

systemic

regional