Exam 4: Peripheral Vascular Disease Flashcards
A 70 yo patient presents c.
Hx of HTN, DM, Hyperlipidemia, Obesity
Hx of tobacco use
Leg claudication/ischemic pain in the calf at rest.
What is this concerning for?
PAD
the four major risk factors for atherosclerosis are…
HTN, DM, Hypercholesterolemia, smoking
At what percent stenosis do sxs begin to appear in atherosclerosis?
70%
what are the common sites for atherosclerosis?
Aortic, iliac, femoral bifurcations
A patient reports a cramping pain in the calf with an inability to walk for more than one block.
This type of pain is called what, and is typical of what disease?
severe claudication, PAD
This syndrome presents with…
Claudication in the buttock, hip or thigh
absent/diminished femoral pulses
erectile dysfunction
Leriche syndrome
A patient with a hx of HTN, smoking, obesity, DM presents with…
Ischemic rest pain (pain in foot aggravated by elevation)
non-healing wounds
Gangrene on the plantar foot.
pallor when elevated, rubor when lowered.
This presentation is indicative of what? Is this an emergent situation?
Critical limb ischemia, emergent!
Who should you perform an ABI in?
patients with LE exertional sxs with risk factors for PAD
this test is the ratio of ankle systolic BP divided by brachial systolic BP
ABI
An ABI of 90 or less with exertional sxs is diagnostic of what condition?
PAD
A pt. presents to the clinic complaining of pain in the foot while resting. It is worse with elevation.
PE shows:
diminished femoral pulses delayed cap refill hair loss on lower extremity cool skin on lower extremity pallor c elevation rubor c. depression
this is concerning for what?
PAD
What is the gold standard diagnostic study for PAD?
contrast angiogram
Arterial duplex doppler ultrasound can be useful to asses for what?
% stenosis, graft patency
When is CTA and/or MRA used?
to plan revascularization
assess size and location of aneurysm
What Txs can help with claudication sxs?
supervised exercise of 30-45 minutes 3 times a week for 12 weeks
cilostazol
A patient with critical limb ischemia or significant sxs that are unresponsive to pharmacologic tx indicate treatment with what?
revascularization via:
Percutaneous transluminal angioplasty
Stents
Atherectomy
Bypass Graft
A patient who just underwent a PTA for PAD is complaining of:
Tissue swelling
significant pain
pain with passive stretch
parasthesias.
What is this suspicious of?
compartment syndrome, a complication of revascularization procedures
What is the most common cause of acute arterial occlusion?
thromboembolism
A patient resents c.:
Parasthesia
Distal pain that has progressed proximally
pallor in limb
diminished pulse
Skin coolness
paralysis
What is this immediately concerning for?
acute arterial occlusion
Paresthesia Pain Pallor Pulselessness Poikilothermia Paralysis
are the 6 Ps of what?
Acute arterial occlusion
A patient presents with sxs concerning for acute arterial occlusion. What should you do to manage the patient?
emergent surgical consultation
+/- antigoaculation, intrarterial thrombolytics
Surgical bypass
amputation
What is a major concern for patients being treated for acute arterial occlusion?
compartment syndrome
This disease is caused by venous hypertension which leads to the dysfunction of venous valves…
chronic venous disease
Age, obesity, prior VTE, pregnancy, smoking, LE trauma, standing occupation are risk factors for what?
chronic venous disease
this disease presents with…
telangiectasia
varicose vein
chronic venous insufficiency
chronic venous disease
A 55 yo female patient presents c.
Aching, burning in the LE
Pain relieved by elevation, worse with standing
varicosities
Telangiectasia.
This is concerning for what?
chronic venous disease
A patient c. hx of DVT presents to the clinic with…
“heavy leg”
burning pain worse c standing
pain relief c. elevation, walking
significant edema
Hemosiderin staining
ulcer on medial malleolus.
This presentation is concerning for…
chronic venous insufficiency
Your patient whom you suspect has chronic venous insufficiency should be diagnosed with what studies?
Venous duplex doppler US
OR
Venography
Your venous duplex doppler US was positive for valvular insufficiency, vein wall thickening, and thrombosis.
this indicates chronic venous insufficiency.
How are you going to treat the patient?
Pt. edu on exercise and wight loss.
elevation of legs for 30 minutes 3-4 times daily
Compression therapy
When is compression therapy contraindicated?
if moderate to severe PAD, cellulitis, DVT
A patient presents with..
erythema, pruritis, vesicles, scaling and inflammation of medial ankle.
What do you suspect, what can confirm, and how should it be treated?
Suspect stasis dermatitis
clinical diagnosis, but can order doppler US
tx with emollients, barrier creams +/- CS
prior to initiating compression therapy, what MUST be r/o?
ischemia
Pain worse c standing
relief c elevation
discomfort c. limb dependency
ulcers…
this indicates what.
Peripheral venous disease
pain c. walking, resolved c. rest
cramping
worsening pain c. elevation
relief of pain in dependent position
ulcers.
this indicates what?
PAD
What type of ulcer presents w:
toe joints, malleoli, ant. shin, base of heel, pressure points
dry, pale, necrotic tissue
diminished pulses
loss of hair, taut skin
pallor c. elevation
Arterial ulcer
What type of ulcer presents c.
located at malleoli above prominance, posterior calf, large/circumferential
base is pink/red with yellow tissue, exudates
pulses present
skin erythema, hyperpigmentation, edema, varicosities
Venous ulcer
How do you treat ulcers?
debridement + dressings
unna bood: zinc paste bandage
What is the most common cause of aortic aneurysm?
atherosclerosis
This aortic dissection involves the arch proximal to the left subclavian artery.
It is a worse prognosis
Type A
This aortic dissection involves the proximal descending thoracic aorta
Type B
A patient c. hx of atherosclerosis presents with:
sudden onset of severe CP, radiating to back
syncope
CVA sxs
AMS
This is extremely concerning for what?
Aortic dissection
A patient arrives to the ED. You perform a PE and observe the following:
HTN
AMS
Ptosis, Anhidrosis, Miosis
Diminished pulses
The patient is complaining of severe chest pain.
This is concerning for…
Aortic dissection
You suspect a patient is suffering an aortic dissection. How do you make ur diagnosis?
CT Chest and Abdomen
CXR showing widened mediastinum
Aortic dissection requires what interventions?
urgent surgical consult
immediate control of BP via beta-blockers
What percentage of aortic aneurisms are TAA?
< 10%
Do most patients suffering from TAA have sxs?
no
A patient presents with the following:
Cardio:
+JVD, + substernal CP
Pulm:
+Dyspnea, stridor, cough
Skin:
+ Edema in UE, neck
HEENT:
hoarseness
This is concerning for what?
TAA
if you suspect TAA, what should you order?
CT
What is the most common site for AAA?
infrarenal abdominal aorta
80% of patients have a AAA that is palpable with a size of…
5cm
When do most AAA develop sxs?
rupture
A 60 yo male pt. is presenting to the ED with:
Severe abdominal pain radiating to the back
Pulsitile abdominal mass
extreme tenderness
Rapidly developing hypotension
This is concerning for…
AAA
How do you screen for AAA?
abdominal US
one time abdominal US screening for AAA is indicated for what populations?
65-75 yo men c hx of tobacco OR relative who had AAA
When should CT scan be performed when evaluating AAA?
when aneurysm nears 5.5cm diameter
When should you refer a AAA to a vascular specialist?
4cm or greater
What are the indications for repair of AAA?
> 5.5 cm
rapid growth of > 0.5 cm in 6 mo
A patient is presenting to the clinic with the following sxs:
TIA sxs
Amaurosis Fugas (transient monocular blindness
Contralateral weakness of face
PE reveals:
carotid bruit
absent pupillary light reflex
What do you suspect? What should you expect to see on fundoscopic exam
Dx: Carotid artery stenosis
fundoscope: arterial occlusion, ischemic damage to retina, hollenhorst plaque
How do you diagnose carotid artery stenosis?
carotid duplex ultrasound + cerebral angiography +/- MRA/CTA
What percent of stenosis indicates severe carotid artery stenosis?
What about moderate?
70%
50-69%
if carotid artery stenosis is symptomatic, what should treatment consist of?
revascularization via:
- carotid endarterectomy (CEA)
- carotid artery stent
PAD should primarily be handled via lifestyle modification and aggressive risk factor reduction. this includes…
antiplatelet therapy (plavix)
smoking cessation
Statins
HTN, hyperglycemia control
weight management
what procedure can be performed after revascularization to prevent the development of compartment syndrome?
fasciotomy
