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Cardio Week 5 > ICL 4.2: Clinical Peripheral Vascular Disease & Management > Flashcards

ICL 4.2: Clinical Peripheral Vascular Disease & Management Flashcards

1
Q

what is the prevalence of PAD?

A

it varies based on the population, Methods and symptoms included

it’s present in 4% of people 40 years of age and older but in 15-20% in those 65+

men > women

african american > white

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2
Q

what other conditions are associated with PAD?1

A
  1. CVD
  2. CAD
  3. 30% of patients with DM and tobacco use
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3
Q

what is the prognosis for PAD?

A
  1. increased risk for adverse cardiovascular events

the risk of death from cardiovascular causes increases 2.5- to 6-fold in patients with PAD, and their annual mortality rate is 4.3 to 4.9%

  1. increased risk of limb loss and impaired quality of life

25% of patients with critical limb ischemia die within 1 year, and the 1-year mortality rate among patients who have undergone amputation for PAD may be as high as 45%

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4
Q

what is the 5 and 10 year mortality of PAD?

A

28% to 50%

the more severe the PAD the higher the mortality

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5
Q

what are the risk factors for PAD?

A
  1. smoking
  2. DM
  3. HTN
  4. hypercholesterolemia
  5. hyperhomocysteinemia
  6. CRP
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6
Q

what is the clinical presentation of PAD?

A
  1. asymptomatic –> 50% don’t have symptoms!!! so you have to actively look for PAD
  2. atypical leg pain (33%) with functional limitations
  3. claudication (15%)
  4. critical limb ischemia (1-2%)
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7
Q

what is Intermittent claudication?

A

discomfort, ache, cramping in leg with exercise

resolves with rest

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8
Q

what is rest pain?

A

pain or paresthesias in foot or toes typically occurs at night

worsened by leg elevation and improved by dependency/danging their legs

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9
Q

based on the arterial occlusion site, where would the patient feel pain?

A
  1. aortic/iliac occlusion –> gluteal and thigh pain
  2. femoral occlusion –> popliteal/tibial occclusion = calf
  3. popliteal/tibial occlusion –> calf or foot pain
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10
Q

what are the syndromes that incidicuals with PAD present with?

A
  1. critical limb ischemia

2. acute limb ischemia

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11
Q

what is critical limb ischemia?

A

Ischemic rest pain, non-healing wound, or gangrene and symptoms with a duration > 2 weeks

this is the most urgent presentation in people who have PAD?

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12
Q

what is acute limb ischemia?

A

the “5 P’s” defined by the clinical symptoms and signs with a duration less than 2 weeks

Pain
Pulselessness
Pallor
Parasthesias
Paralysis

there’s no time for collateral circulation to develop

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13
Q

54 yo male with no significant PMH presents with a 2-month history of bilateral lower extremity cramping, worsened by exertion or standing for long periods of time, relieved by sitting/leaning forward or lying on his side

Exam reveals intact pedal pulses and diminished bilateral lower extremity DTRs

diagnosis?

A

nonvascular; sounds like a nerve issue because he has intact pedal pulses but diminished bilateral lower extremity reflexes

lower extremity pain doesn’t always mean vascular issues

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14
Q

what other conditions may cause lower extremity pain other than vascular issues?

A

several nonvascular causes of exertional leg pain should be considered in patients who present with symptoms suggestive of intermittent claudication

lumbosacral radiculopathy resulting from degenerative joint disease, spinal stenosis, and herniated discs can cause pain in the buttock, hip, thigh, calf, and/or foot with walking, often after short distances or even with standing

the term ‘pseudoclaudication’ has been used to describe this symptom

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15
Q

how can you differentiate between claudication and psuedoclaudication?

A

CLAUDICATION
cramping tightness aching fatigue

effects buttock, hip, thigh, calf, foot

exercise induced; consistent with distance

does not occur with standing

for relief, stand or stop walking and it takes under 5 minutes

PSEUDO
cramping tightness aching fatigue + tingling, burning and numbness

same locations effected so can’t rely on this

variable if induced by exercise or distance

occurs with standing

for relief, sit, lean forward, and change positions and it takes 30 minutes

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16
Q

what are the PE findings in PAD?

A

the complete cardiovascular examination includes palpation of pulses and auscultation of accessible arteries for bruits

pulse abnormalities and bruits increase the likelihood of PAD

a decreased or absent pulse provides insight into the location of arterial stenoses

but remember, you might not find anything wrong with the patient!!

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17
Q

what is included in a comprehensive vascular examination?

A
  1. bilateral arm BP
  2. cardiac exam
  3. palpation of the abdomen for aneurysm disase
  4. auscultation for bruits
  5. examination of legs and feel
  6. pulse deamination everywhere = carotid, radial, femoral, popliteal, dorsalis pedis, posterior tibial
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18
Q

what is the scale for describing pulses?

A

0 = absent

1 = diminished

2 = normal

3 = bounding

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19
Q

what are the physical findings you may see in PAD?

A
  1. loss of hair on the lower calf
  2. skin thickening
  3. coolness
  4. arterial ulcers
20
Q

what are arterial ulcers?

A

typically have a pale base with irregular borders and usually involve the tips of the toes or the heel of the foot, or they develop at sites of pressure

these ulcers vary in size and may be as small as 3 to 5 mm

21
Q

what tests do you do to test for peripheral arterial disease?

A
  1. ABI
  2. PVR, segmental pressures
  3. treadmill test
  4. duplex US, CTA, MRA, angiography
22
Q

what is ABI?

A

an easy test you can do at the bedside when you suspect PAD in the lower extremities – ankle and brachial systolic pressures are taken using a handheld doppler

ABI = ankle systolic pressure/ brachial systolic pressure

the peripheral pulse is exaggerated as you go away from the heart into the periphery because the arterial waveform and compliance are amplified

95% sensitive and 99% specific for PAD

23
Q

what is a normal range for ABI?

A

normal = 1 - 1.4

borderline = 0.91-0.99

PAD = < .9

pain/ulceration = < 0.4

noncompressible > 1/4

24
Q

what are the limitations of ABI testing?

A
  1. calcified vessels lead to falsely elevated pressures in the ankle and therefore a falsely normal or supernormal ABI
  2. doesn’t provide anatomical information; doesn’t tell you where the stenosis is just that they have PAD
25
Q

what are segmental pressures?

A

put BP cups at the high thigh, low thigh, high calk, ankle and toe

a waveform and BP is recorded at each location

if there’s a pressure drop of more than 20 mmHg between cuffs, that indicates there’s a stenoses between them that’s proximal to the area of dropped pressure

26
Q

how is treadmill testing used to diagnose PAD?

A

if the patient has normal ABI but you’re concerned they have underlying disease processes, do the treadmill test

dxercise uncovers disease because at rest arteries have high resistance but exercise decreases resistance leading to a drop in pressure

an ABI fall post exercise supports a PAD diagnosis

27
Q

how is duplex ultrasound imagining used to diagnose PAD?

A

it shows us direction and speed of blood flow in the arteries

high velocity flow is typical of stenoses

28
Q

how is computed tomographic angiography used to diagnose PAD?

A

super fancy 3D representation of all there arteries to show you if there’s occlusions

29
Q

what do you do once you’ve diagnosed the patient with presumed PAD?

A

invasive contract angiography using iodine or other contrast

this is done before a revasculartization procedure

30
Q

what are the goals of treatment for PAD?

A
  1. reduction in cardiovascular morbidity and mortality

once you diagnose someone with PAD, they have an increased risk for mortality and it’s highest due to cardiovascular problems, not peripheral problems

  1. improvement in quality of life by decreasing symptoms of claudication, eliminating rest pain
  2. preserving limb viability
31
Q

how do you decrease the risk of MI, stroke and CV death in patients who have PAD?

A
  1. smoking cessations
  2. walking program
  3. control BP to goal
  4. high dose statin therapy
  5. anti platelet therapy
32
Q

how do you improve symptoms, quality of life and prevent amputation in patients with PAD?

A
  1. smoking cessation
  2. walking program
  3. cilostazol = decrease symptoms
  4. good foot care = moisturizing cream, nail care, treat and prevent tine, orthotics to prevent abnormal pressure points
  5. revascularization
33
Q

how does smoking cessation help with PAD?

A

Nonsmokers with PAD have lower rates of myocardial infarction and mortality than those who have smoked or continue to smoke

PAD patients who discontinue smoking have approximately twice the 5-year survival rate of those who continue to smoke

smoking cessation also lowers the risk of developing critical limb ischemia

34
Q

how does anti platelet help with PAD?

A

there’s substantial evidence supports the use of antiplatelet agents to reduce adverse cardiovascular outcomes in patients with atherosclerosis

the Clopidogrel vs. Aspirin in Patients at Risk for Ischemic Events (CAPRIE) trial compared clopidogrel with aspirin in terms of efficacy in preventing ischemic events in patients with recent myocardial infarction, recent ischemic stroke, or PAD

overall, there was an 8.7% relative risk reduction for myocardial infarction, ischemic stroke, or cardiovascular death in the group treated with clopidogrel

35
Q

how does exercise rehab help with PAD?

A

supervised exercise rehabilitation programs improve symptoms of claudication in patients with PAD

meta-analyses of controlled studies of exercise rehabilitation found that supervised exercise programs increase the average distance walked to the onset of claudication by 180% and the maximal distance walked by 120 to 150%

the goal of each session is to reach maximal claudication pain because that elicits recruitment of collateral vessels and subsequent decrease in pain

it’s proven to be effective in increasing maximal walking distance

you need to walk 30 minutes per session, for at least 3 sessions/week for 6+ months

36
Q

when do you consider revascularization in patients with PAD?

A

if the patient has lifestyle limiting claudication with an inadequate response to guideline directed medical therapy

so the patient has to have lifestyle limiting; not just discomfort

and you have to have done all the proper GDMT

37
Q

what does PTA stand for?

A

PTA = percutaneous transluminal angioplasty

invasive therapy for PAD

38
Q

when is PTA indicated for patients with PAD?

A

peripheral catheter-based interventions are indicated for:

  1. lifestyle-limiting claudication despite a trial of exercise rehabilitation or pharmacotherapy
  2. symptomatic patients and clinical evidence of inflow disease, as manifest by buttock or thigh claudication and diminished femoral pulses
  3. critical limb ischemia whose anatomy is amenable to catheter-based therapy
39
Q

what’s the difference between claudication vs. critical limb ischemia?

A

claudication = disabling, lifestyle limiting –> kind of like someone having angina

treat whenever; the goal is patency to try and open up vessels to save the limb

critical limb ischemia = tissue loss/ischemia, rest pain or refractory infection –> this is like someone having acute coronary syndrome because the baseline blood supply is inadequate for the limb

treat ASAP!! the goal is limb salvage

40
Q

what are the various endovascular interventions that can be done to treat a PDA?

A
  1. angioplasty
  2. stents
  3. rotational atherectomy
  4. catheter delivered thrombolytic therapy
  5. rheolytic thrombectomy devices
  6. photo-activation of drugs

although historically the primary method of revascularization therapy for PAD involved surgery, percutaneous catheter-based or endovascular therapies now provide patients with a less invasive and equally effective modality for the treatment of atheromatous disease in almost all vascular territories

41
Q

how can you differentiate between the superficial femoral artery and the deep?

A

SFA doesn’t have any branches in the thigh

the profunda has muscular branches!

42
Q

when do you consider surgical revascularization in patient with PAD?

A
  1. to improve quality of life in patients with disabling claudication on maximal medical therapy and
  2. to relieve rest pain and preserve limb viability in patients with critical limb ischemia not amenable to percutaneous interventions

the operative mortality rate for extra-anatomic bypass procedures is 2-5%, reflecting in part the serious comorbid conditions and advanced atherosclerosis of many of the patients who undergo these procedures

43
Q

what is aorta-bifemoral bypass?

A

aorta-bifemoral bypass is the most frequent operation for patients with aortoiliac disease

it’s a knitted or woven prosthesis made of Dacron or polytetrafluoroethylene (PTFE) is anastomosed proximally to the aorta (‘Aorto-’) and distally to each common femoral artery (‘-bifemoral’)

44
Q

what are the pros vs. cons of open vs. endovascular approaches?

A

OPEN
1. excellent long-term patency rate

  1. 85%–90% at 5 years
  2. requires general anesthesia
  3. 1%-3% mortality rate

ENDOVASCULAR
1. high procedural success rates (90%)

  1. excellent long-term patency (>80-90% at 5 years (or even better))
  2. less morbidity/mortality
45
Q

what is the TASC classification of revascularzation?

A

type A-D

categories of lesions in different vascular beds as progressively more complicated

so there are categories and classifications that help decide the best modality for the patient

endovascular first in type A and B and sorta C – surgery first in type D

46
Q

what is the management algorithm for patients with PAD?

A

if a patient with PAD present with CLI, you go immediately to localizing the lesion and then revascularization from the get go

if they have PAD and present with claudication, take an HPI and do testing to confirm PAD – then give anti platelet therapy with supervised exercise – if symptoms improve continue therapy and don’t do revascularization

however, if their symptoms deteriorate,localize the lesion and chose a revascularization modality

Cardio Week 5 (5 decks)

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