ARTERIAL DISEASES OF THE EXTREMITIES

Question 1

The most typical symptom of PAD is

Answer 1

intermittent claudication, which is defined as a pain, ache, cramp, numbness, or a sense of fatigue in the muscles. It occurs during exercise and is relieved by rest.

Question 2

ABI that is diagnostic of PAD

Answer 2

<0.90

• 1.00–1.40 in normal individuals.
• 0.91–0.99 are considered “borderline”
• <0.90 are abnormal and diagnostic of PAD
• > 1.40 indicate non-compressible arteries secondary to vascular calcification

Question 3

A non-invasive test that allows the physician to assess functional limitations objectively in patients with PAD

Answer 3

Treadmill testing

Question 4

TRUE OR FALSE: Patients with claudication should be encouraged to exercise regularly and at progressively more strenuous levels.

Answer 4

TRUE

• Supervised exercise training programs for 30- to 45-min sessions, at least three per week for 12 weeks, prolong walking distance.

Question 5

It is a phosphodiesterase inhibitor with vasodilator and antiplatelet properties, increases claudication distance by 40–60% and improves measures of quality of life.

Answer 5

CILOSTAZOL

Question 6

It is a protease activated receptor-1 antagonist that inhibits thrombin mediated platelet activation

Answer 6

VORAXAPAR

• When added to other antiplatelet therapy, this drug decreases the risk of adverse cardiovascular events in patients with atherosclerosis, including PAD.
• Reduces the risk of acute limb ischemia and peripheral revascularization

Question 7

What limb arteries are most likely to be affected by fibromuscular dysplasia

Answer 7

Iliac arteries

* Identified angiographically by a “string of beads” multifocal appearance caused by thickened fibromuscular ridges contiguous with thin, less-involved portions of the arterial wall, or less commonly, as a focal tubular stenosis

Question 8

TRIAD of thomboangitis obliterans

Answer 8

• Claudication of the affected extremity
• Raynaud’s phenomenon
• Migratory superficial vein thrombophlebitis

Question 9

TRUE OR FALSE: There is no specific treatment except abstention from tobacco

Answer 9

TRUE

Question 10

TRUE OR FALSE: Buerger’s disease is an inflammatory occlusive vascular disorder involving small and medium-sized arteries and veins in the distal upper and lower extremities

Answer 10

TRUE

Question 11

TRUE OR FALSE: Once the diagnosis of ALI is made, the patient should be anticoagulated with intravenous heparin to prevent propagation of the clot and recurrent embolism.

Answer 11

TRUE

• Occurs when arterial occlusion results in the sudden cessation of blood flow to an extremity
• Principal causes of acute arterial occlusion include embolism, thrombus in situ, arterial dissection, and trauma

Question 12

What is the most effective therapy for ALI when acute arterial occlusion is recent (<2 weeks)

Answer 12

Intra-arterial thrombolytic therapy with recombinant tissue plasminogen activator, reteplase, or tenecteplase is most effective when acute arterial occlusion is recent (<2 weeks)

Question 13

It is preferred when restoration of blood flow must occur within 24h to prevent limb loss or when symptoms of occlusion have been present for >2 weeks.

Answer 13

Surgical revascularization

Question 14

What is the ideal management when the limb is not viable, as characterized by loss of sensation, paralysis, and the absence of Doppler

Answer 14

Amputation

Question 15

Another cause of limb ischemia due to multiple small deposits of fibrin, platelets, and cholesterol debris that embolize from proximal atherosclerotic lesions or aneurysmal sites.

Answer 15

Atheroembolism

• Large protruding aortic atheromas are a source of emboli that may lead to limb ischemia
• Neither surgical revascularization procedures nor thrombolytic therapy is helpful because of the multiplicity, composition, and distal location of the emboli.

Question 16

It is a symptom complex resulting from compression of the neurovascular bundle (artery, vein, or nerves) at the thoracic outlet as it courses through the neck and shoulder

Answer 16

THORACIC OUTLET COMPRESSION SYNDROME

• Thoracic outlet compression syndrome is divided into arterial, venous, and neurogenic forms.

Question 17

The term for venous compression that may cause thrombosis of the subclavian and axillary veins that is often associated with effort

Answer 17

Paget-Schroetter syndrome

Question 18

It is an abnormal communication between an artery and a vein, bypassing the capillary bed

Answer 18

ARTERIOVENOUS FISTULA

• Congenital arteriovenous fistulas are a result of persistent embryonic vessels that fail to differentiate into arteries and veins.
• Acquired arteriovenous fistulas either are created to provide vascular access for hemodialysis or occur as a result of a penetrating injury such as a gunshot or knife wound or as complications of arterial catheterization or surgical dissection

Question 19

Compression of a large arteriovenous fistula may cause reflex slowing of the heart rate also known as

Answer 19

Nicoladoni-Branham sign

Question 20

Characterized by episodic digital ischemia, manifested clinically by the sequential development of digital blanching, cyanosis, and rubor of the fingers or toes after cold exposure and subsequent rewarming.

Answer 20

RAYNAUD’S PHENOMENON

Question 21

Drugs that have been causally implicated in Raynaud’s phenomenon.

Answer 21

Ergot preparations
methysergide
β-adrenergic receptor antagonists
chemotherapeutic agents bleomycin, vinblastine, cisplatin, and gemcitabine.

Question 22

Which drug treatment for severe cases of Raynaud’s is incorrectly matched:

A. Dihydropyridine calcium channel antagonists (nifedipine, isradipine, felodipine, and amlodipine) - decrease the frequency and severity of Raynaud’s phenomenon.
B. Postsynaptic α1-adrenergic antagonist (prazosin) - used with favorable response
C. Phosphodiesterase type 5 inhibitors (sildenafil, tadalafil, and vardenafil) - may improve symptoms in patients with secondary Raynaud’s phenomenon
D. None of the above

Answer 22

All are correctly matched

Question 23

Characterized by arterial vasoconstriction and secondary dilation of the capillaries and venules with resulting persistent cyanosis of the hands and, less frequently, the feet.

Answer 23

Acrocyanosis

Question 24

TRUE OR FALSE: Secondary acrocyanosis can be associated with anorexia nervosa syndrome and postural orthostatic tachycardia syndrome

Answer 24

TRUE

Question 25

Localized areas of the extremities develop a mottled or rete (netlike) appearance of reddish to blue discoloration

Answer 25

LIVEDO RETICULARIS

Question 26

Primary livedo reticularis with ulceration is also called

Answer 26

atrophie blanche en plaque

Question 27

The term used to characterize secondary livedo reticularis, when the mottling is irregular and disrupted, and does not improve with warming

Answer 27

Livedo racemosa

Question 28

Burning pain in the extremities that is precipitated by exposure to a warm environment and aggravated by a dependent position

Answer 28

ERYTHROMELALGIA

Question 29

A vasculitic disorder associated with exposure to cold and usually presents with raised erythematous lesions that develop most commonly on the toes or fingers in cold weather

Answer 29

PERNIO (CHILBLAINS)

Question 30

Treatment for pernio

Answer 30

• Sympatholytic drugs and dihydropyridine calcium channel

Question 31

Lipodermatosclerosis: combination of induration, hemosiderin deposition, and inflammation, and typically occurs in the lower part of the leg just above the ankle.
Atrophie blanche: white patch of scar tissue, often with focal telangiectasias and a hyperpigmented border; it usually develops near the medial malleolus
Phlebectasia corona: fan-shaped pattern of intradermal veins near the ankle or on the foot; skin ulceration may occur near the medial and lateral malleoli
Venous ulcer: often shallow and characterized by an irregular border, a base of granulation tissue, and the presence of exudate