Cards: PAD

Question 1

What gender is at higher risk for PAD?

Answer 1

However, unlike other types of arterial disease, the population burden of PAD is higher in women than in men.

Question 2

What is the main clinical spectrum of PAD?

Answer 2

There is a wide spectrum of clinical manifestations for PAD:

Asymptomatic patients found to have PAD from a screening ABI (20%-50%)
Atypical symptoms associated with exercise limitation (40%-50%)
Classic intermittent claudication (10%-35%)
Ischemic pain and ulceration in a lower extremity from chronic limb ischemia (1%-2%)

Question 3

What is PAD considered in terms of overall mortality?

Answer 3

Both asymptomatic and symptomatic patients with PAD are at increased risk of cardiovascular morbidity and mortality, and PAD is considered a coronary heart disease risk equivalent.

Question 4

Who can be screened for PAD?

Answer 4

Screening for peripheral arterial disease (PAD) is reasonable in patients at increased risk for PAD, including those aged 65 years and older, aged 50 to 64 years with risk factors for atherosclerosis or family history of PAD, younger than 50 years with diabetes mellitus and one additional risk factor for atherosclerosis, or with known atherosclerosis in another vascular bed.

Question 5

Clinically, what should you evaluate in patients with PAD?

Answer 5

Patients at risk for PAD should undergo a comprehensive medical history and a vascular review of symptoms to assess walking impairment, claudication, ischemic pain while at rest, and nonhealing wounds

Question 6

What are the differences between claudication and pseudoclaudication?

Answer 6

Table 44

Question 7

What are some physical exam findings of people with PAD?

Answer 7

• diminished, absent, or asymmetric pulses below the level of stenosis, with occasional bruits over stenotic lesions and evidence of poor wound healing
• unilaterally cool extremity; a prolonged venous filling time (>20 seconds)
• shiny atrophied skin
• ulceration
• thickened, ridged, and brittle nails

Question 8

How is upper extremity PAD usually found?

Answer 8

Most patients with upper extremity PAD are asymptomatic, and PAD may be detected only by the finding of asymmetric arm blood pressures, with a typical differential in systolic blood pressures of greater than 15 mm Hg.

Question 9

How to measure ABI?

Answer 9

https://stanfordmedicine25.stanford.edu/the25/ankle-brachial-index.html

Patients should rest for 5 to 10 minutes before measuring the ankle pressure and should be lying flat for an accurate ABI measurement, with the head and heels fully supported. The study is performed by applying a blood pressure cuff to the calf and measuring the systolic blood pressure by palpation or Doppler at the ankle. The blood pressure is recorded for both the dorsalis pedis (DP) and the posterior tibial (PT) arteries, and the higher of the two is used as the ankle pressure. This procedure is repeated for the opposite ankle. The brachial artery systolic blood pressure is measured in a similar fashion in both arms. For the measurement of ABI, measuring the limb pressures in the following order is recommended: first arm, first PT artery, first DP artery, other PT artery, other DP artery, and other arm. If the systolic blood pressure of the first arm exceeds the systolic blood pressure of the other arm by more than 10 mm Hg, measurement of the blood pressure of the first arm should be repeated (to temper the “white coat effect” of the first measurement), and the first measurement of the first arm should be disregarded. For each leg, the ABI is calculated by dividing the ankle pressure by the higher of the two brachial pressures.

Question 10

How can the sensitivity of ABI be increased?

Answer 10

The sensitivity of the ABI is increased when it is measured after exercise. A common exercise protocol involves walking on a treadmill at 2 mph at a 12% incline for 5 minutes or until the patient is forced to stop because of leg pain.

Question 11

When do guidelines recommend PAD treadmill testing?

Answer 11

The 2016 AHA/ACC PAD guideline recommends exercise treadmill ABI testing in all patients with a normal or borderline resting ABI value and exertional leg symptoms that are not joint related. Exercise treadmill ABI can also be beneficial in patients with established PAD to evaluate functional status.

Question 12

What other ways can PAD be diagnosed?

Answer 12

Segmental leg pressures

CTA angiography or MRA

Question 13

When is CTA and MRA used for PAD?

Answer 13

Noninvasive angiography with duplex ultrasound, CT angiography (CTA), or magnetic resonance angiography (MRA) is performed for anatomic delineation of PAD in patients requiring surgical or endovascular intervention.

Question 14

In exercise ABI, how is PAD diagnosed? why is it used?

Answer 14

An exercise ankle-brachial index (ABI) is recommended to establish the diagnosis of peripheral arterial disease (PAD) in patients in whom the resting ABI is equivocal; a decrease of the ABI by 20% after exercise suggests significant PAD.

Question 15

What is the strongest risk factor for PAD?

Answer 15

Smoking

Question 16

How is PAD medically managed?

Answer 16

-Quit smoking
-High intensity statin
-BP Control 130/80
-Aspirin and/or plavix
-

Question 17

How do you treat for symptoms relief with PAD?

Answer 17

• Exercise rehabilitation (strong evidence)

- Cilosazol

Question 18

When is endovascular or surgical revascularization indicated?

Answer 18

Endovascular or surgical revascularization is indicated for patients with significant disability due to claudication who have had an inadequate response to exercise or pharmacologic therapy, provided the benefits outweigh the risks.

Question 19

Who should be considered for immediate surgical revascularization?

Answer 19

Patients with critical limb ischemia (ABI <0.40, a flat waveform on pulse volume recording, and low or absent pedal flow on duplex ultrasonography) should be considered for immediate revascularization, either surgical or endovascular.

Question 20

What are the 6 Ps of PAD?

Answer 20

Acute limb ischemia is an uncommon manifestation of PAD that carries significant risk of morbidity and mortality. Physical findings are characterized by the “6Ps”—Paresthesia, Pain, Pallor, Pulselessness, Poikilothermia (coolness), and Paralysis.

Question 21

When a diagnosis of acute limb ischemia is made, what steps should follow next management wise?

Answer 21

Anticoagulation should be started as soon as the diagnosis has been made. Early consultation with a vascular specialist is appropriate. Patients with acute limb ischemia and a salvageable extremity should undergo emergent angiography to define the anatomic level of occlusion and assess treatment options. Treatment consists of catheter-based thrombolytic therapy or surgical or percutaneous revascularization and is selected based on patient factors and local resources. Catheter-directed thrombolysis is effective in patients with a viable or marginally threatened limb, recent occlusion (no more than 2 weeks’ duration), thrombosis of a synthetic graft, or an occluded stent. Although many patients will require revascularization following thrombolysis, the procedure is frequently less complex than if thrombolysis was not performed.

Question 22

What side effects should be monitored for after limb reperfusion?

Answer 22

Following limb reperfusion, close monitoring is required for limb edema and tissue swelling that may cause a compartment syndrome. Symptoms and signs include severe pain, hypoesthesia, and weakness of the affected limb; myoglobinuria and increased serum creatine kinase levels often occur. If the compartment syndrome occurs, surgical fasciotomy is indicated to prevent irreversible neurologic and soft-tissue damage.