Chapter Eleven - Peripheral Arterial Disease Flashcards
What does PAD mean? Give some examples. What are some common signs and symptoms?
What is PAD?
– Occlusive disease
– Inflammatory disease
– Aneurysm
Signs and symptoms
– Acute vs chronic ischemia
– Intermittent claudication
– Aneurysm
- Diagnosis
- Medical management
- Surgical management
- Exercise management
- Case study
Where is PAD more common?
Arterial pathology more common in lower extremities than upper
• Major abdominal organs
– Kidneys
– Intestines
PAD is a strong predictor for a lot of pathologies. Which ones?
Common manifestation of atherosclerosis
Associated with higher risk of MI, stroke, and death
Increased risk of renal failure, limb loss, death
Under-diagnosed and under-treated!
Incidence increases with age and accumulation of risk factors
* Possible cognitive changes: can lead to vascular dementia (decreased blood flow to the brain)
What are some of PAD’s risk factors?
- Smoking (Biggest bang for your buck in terms of reducing risk of PAD)
- Diabetes (Talk to patients about the importance of blood-glucose control, proper footwear, checking the skin on their feet)
- Hypertension
• Dyslipidemia
- Age
- Gender
- Family History
- Thrombogenic factors
- Obesity
- Sedentary lifestyle
What is Peripheral Arterial Occlusive Disease ?
Atherosclerosis of the abdominal aorta, iliac, and lower extremity arteries leading to stenosis or occlusion
Occlusive disease accounts for 95% of cases
Progressive
Symptoms occur distal to stenosis or occlusion
May lead to limb loss, death
Often leads to decreased quality of life, decreased function
What are Peripheral Arterial Occlusive Disease’s S&S?
Pain
– Claudication (Often: reversible muscle ischemia (muscle can’t get enough blood to supply for the activity of that tissue))
– Ischemic rest pain (Worst when the foot is elevated: decreased blood flow)
Weak or absent pulses in the legs or feet
Pale limb color, cool temperature
Poor nail growth, decreased hair growth on the legs
Poor wound healing
Erectile dysfunction
How do you diagnose peripheral arterial occlusive disease?
• ABI
- Ankle Brachial Index
- Screening test for PAD measured with BP cuff (With stethoscope or doppler machine)
- ABI = Pleg / Parm (ratio of blood flow)
Results
• >1.30 means the vessels are noncompressible (Blood flow to lower extremity is higher than blood flow to their arms)
- 0.91-1.30 is normal result
- 0.41-0.90 is mild-to-moderate PAD
- 0.00-0.40 is severe PAD
* Out of our scope of practice but we can still do the test and report the results to the physician. We still need to understand the tests
What is the difference between Doppler and the Duplex scan for vessel visualization?
• Doppler
– Assessment of pulses
• Carotid, brachial, radial, ulnar
• Femoral, popliteal, posterior tibial, dorsalis pedis
• Duplex scan
– Creates picture of
vessel
– Generates graph of waveform
What is CTA? Describe the procedure briefly. What are two other imaging techniques?
CTA (CT with angiography) (imaging)
Inject patient with dye, and look to see where the dye goes. In this case, occlusion to the popliteal artery with collateral branching to detour the blockage
MRA
– Magnetic Resonance Angiography
Angiogram (live version of it)
What is chronic ischemia? What is its classic symptom? Explain why and what causes it.
Chronic Ischemia
- Progressive narrowing of arteries due to atherosclerosis
- Classic symptom is Intermittent Claudication
– Sensation of pain, fatigue in the legs
- Can be sharp pain, aching, throbbing, burning
- Severity and location determined by location of occlusion, degree of collateral flow
– Predictably brought on by exercise, relieved easily by rest
– Caused by decreased blood flow to the muscles (think of angina
What can an incomplete occlusion result in overtime? What can severe critical limb ischemia imply, and what can it lead to?
Incomplete occlusion can result in the development of collateral vessels over time
Severe PAD can lead to critical limb ischemia
– Pain at rest
– Night pain
– Ulceration
– Gangrene (We have dry gangrene (let the toes auto-amputate), vs wet gangrene (most dangerous))
Can become limb and life-threatening – requires revascularization, if severe enough, amputation
What is acute ischemia? What can it be caused by?
Acute Ischemia
- Sudden onset from acute occlusion of artery
- MEDICAL EMERGENCY
• May be caused by
– Embolus (Afib, ventricular aneurysm, atrial
myxoma, ulcerated plaque) – Aneurysm thrombosis
– Graft occlusion
• May have loss of sensation and motor function
What is an aneurysm? Which is the most common and what are other forms?
- Abnormal dilation in the wall of an artery 50% greater than normal
- Abdominal aortic aneurysm (AAA) most common
- Thoracic aorta, iliac, femoral, and popliteal
What causes an aneurysm?
- Atherosclerosis
- Injury to tunica media
- Connective tissue and inflammatory diseases
• Can be hereditary
– 1st degree relative with aneurysm = 4x increased
risk
• More common in men than women
What are the symptoms of an aneurysm?
• Depends on size and location
– Pain may occur locally as aneurysm impinges adjacent structures
• Abdominal and/or low back pain may be present (this may be the only symptom pre- rupture) in AAA
• Pulsatile mass
– >2cm in popliteal aneurysms
What are the treatments of an aneurysm?
• Regular monitoring
• Risk factor management
– Smoking cessation, BP control, cholesterol management, regular exercise
• Surgical intervention – Open repair
– Endovascular repair (EVAR: endovascular aneurysm repair)
What is Buerger’s disease (Thromboangiitis Obliterans)?
Buerger’s disease (Thromboangiitis Obliterans)
• Rare form of vasculitis affecting peripheral blood vessels – inflammation of vessels
- No known cause
- Found in smokers under 45 yrs old
• First noted in hands, feet
What are some forms of medical management of peripheral artery disease?
Medical Management
Goal is to slow disease progression
Improve cardiovascular risk factors
– Smoking cessation
– HTN treatment
– Cholesterol
Anticoagulation (sometimes)
Exercise therapy
Protect limb from harm!
Protection of ulcers
– Offloading or NWB
– Gait aid prescription
Surgical management: what is thrombolysis?
Catheter inserted into thrombus, lytic agent released, thrombus dissolves
Surgical management: what is angioplasty?
– Catheter uses balloon to open artery
– Stent may be placed
– Minimally invasive
Surgical management: what is endarterectomy?
– Incision made superficial to vessel
– Plaque is removed, vessel patched or sewn up
Surgical management: what is bypass?
– Incisions made proximal and distal to occlusion
– Synthetic graft or reverse vein graft
Surgical management: what is fasciotomy? What does it treat?
Surgical management: what is an amputation? What are some examples?
– Removal of ischemic, infected tissue
– Toe amputation
– Transmetatarsal amputation (TMA)
– Trans-tibial or Below- knee amputation (BKA)
– Trans-femoral or Above-knee amputation (AKA)
