Case of the week: Peripheral arterial disease

Question 1

Why diagnose PAD if you aren’t going to perform an intervention?

Answer 1

it affects the long term cardiovascular health of the patient

**these patients are at increased risk of MI and strokes, and have decreased overall survival

Question 2

Some patients with PAD may be asymptomatic, while others have severe symptoms. What symptoms might you see in these patients?

Answer 2

severe ischemia leading to claudication and necrosis/tissue loss, atypical exertional leg pain

Question 3

Which artery/arteries are most likely to be occluded leading to PAD?

Answer 3

superficial femoral

**most commonly occluded artery in the body, damaged by cigarette smoking, can have few symptoms bc the deep femoral compensates

Question 4

What can cause intermittent claudication?

Answer 4

atherosclerosis
Buerger’s disease
vasculitis
fibromuscular disease

Question 5

Symptoms of PAD

Answer 5

fatigue, aching calves w exercise relieved by rest (classic)
hip and buttock pain
pain in toes
weakness/tiredness
non-healing ulcer
infection

**rubor because the capillaries are massively dilated to try to get blood to the foot

Question 6

What might you see on physical exam in PAD?

Answer 6

femoral bruits
diminished pulse
skin, hair, nail changes
dependent rubor, pallor with elevation
ulceration

Question 7

What are some symptoms of blood return (vein) problems?

Answer 7

swelling
varicose veins
pain at the end of the day

Question 8

How do you measure ABI?

Answer 8

take BP in both arms and at both ankles; ABI(R) use highest right foot BP/highest arm BP; ABI(L) use highest left foot BP/highest arm BP

• *normal is between 1.01 and 1.30
• *if ABI is higher than 1.3, suggestive of calcified vessels

Question 9

What other tests might you order after the ABI if you are thinking about doing an intervention?

Answer 9

arterial duplex
segmental pressures
angiogram **gold standard for diagnosis

Question 10

If you have “one level” of disease, or one block in vasculature, what might your ABI be like? Two levels? Three levels?

Answer 10

0. 6-0.8
1. 3-0.6

<0.3

**should be greater than 0.1

Question 11

T/F: In PAD, you always hurt one level below the blockage

Answer 11

True

ex: if blockage in aortic/iliac segment, might present with pain in thigh/butt

Question 12

What are indications for intervention in PAD?

Answer 12

Lifestyle limiting claudication?
Unresponsive to medical therapy?
Do they have rest pain?
Do they have tissue loss/a non-healing ulcer?

• *don’t treat asymptomatic or minimally symptomatic disease
• *with a stent or bypass graft, their risk of adverse events actually becomes worse!

Question 13

This artery is easy to open up & perform an intervention on (if patient is having symptoms, might be easy to fix); this artery is more challenging to perform an intervention on

Answer 13

iliac artery; superficial femoral artery

Question 14

What can be done to help relieve symptoms of claudication in PAD?

Answer 14

Cilostazol (makes RBCs more “slippery”)
supervised exercise therapy (walk until you begin to have symptoms, walk a bit further, stop & rest, then begin to walk again)

Question 15

Types of medical therapy for PAD

Answer 15

antiplatelet therapy (ASA)
lipid management: initiate statin therapy w moderate potentcy stain in pts greater than 75 and high potency in patients less than 75
blood pressure management
diabetes management