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Health Studies > Intermittent Claudication Roop/Jaffe > Flashcards

Intermittent Claudication Roop/Jaffe Flashcards

1
Q

Segmental blood pressure readings show a marked _________ in bp when measured at the calf

A

decrease

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2
Q

What are segmental blood pressures?

A

measures BP in lower limb to check arteriolar blood flow/occlusions (decreased in IC when measured at the calf)

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3
Q

Pulse volume readings (PVR) are also reduced in the calf (like segmental blood pressures). What is a PVR?

A

checking for how much blood is flowing at the arteries

(measures blood pressure and rate of blood flow in arteries of legs)

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4
Q

What is ankle-brachial index (ABI)?

A

checks for peripheral artery disease (PAD) by comparing BP in upper and lower limbs

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5
Q

What is a concerning ankle-brachial index (ABI)?

A

0.8 or less refer to vascular specialist

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6
Q

Duplex ultrasound imaging shows an _________ lumen blood flow velocity in both calves

A

increased

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7
Q

What is duplex ultrasound imaging and what does the increased lumen blood flow indicate?

A

duplex ultrasound involves high frequency sound waves to look at the speed of blood flow /structure of leg veins

it shows clots and plaques

increase lumen blood flow = turbulent flow

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8
Q

What is a contrast angiography?

A

uses contrast dye for pictures of blood vessels

widespread arterial calcifications in the arteries distal to the knee

shows aneurysms , calcifications, plaques, etc.

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9
Q

What determines blood flow? What is the eq?

A

Q= delta P/ R

Blood flow is directly proportional to the pressure gradient and inversely proportional to resistance

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10
Q

What determines vascular resistance?

A

viscosity of blood, and length + radius of blood vessel

1) local metabolic control (metabolic = autoregulation)
2) sympathetic nerves (sympathetic NS vasoconstricts blood vessels)
3) circulating vasoactive hormones (angiotensin 2 is one of the most potent vasoconstrictors)

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11
Q

During exercise, skeletal muscle blood flow can increase _____ from perfusion of all the capillaries in the skeletal muscle bed as well as vasodilation of the arterioles in the precapillary sphincters.

A

10x

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12
Q

What causes dilation in exercising muscles?

A

-hypoxia (vasodilator)
-metabolic waste (vasodilator)

(only 25% of capillaries are perfused at rest, this increases 10x during exercise)

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13
Q

Explain what is happening with an atherosclerotic plaque

A

-decreased radius = stenosis
-downstream from the plaque = vasodilation (during exercise cannot vasodilate anymore so results in cramps and pain)

Blood vessels continually lay down collagen → less compliant → increase pressure and HR to compensate → hypertension → heart overworks → cardiomegaly and hypertrophy

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14
Q

What are the risk factors for the development of the atherosclerositic plaques?

A

-HTN (HTN damages blood vessel → inflammation causes more cells to stick to endothelium)
-Diabetes (Increase of inflammatory cytokines and WBC → will stick to fatty streaks → stenosis of blood vessel)
-Smoking
-Cardiovascular disease
-hyperlipidemia

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15
Q

Intermittent claudication is the hallmark of…..

A

PAD (peripheral artery disease)

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16
Q

What are the key elements of peripheral arterial disease (PAD)?

A

1) Pts w/ PAD have 6x the mortality as their age and gender-matched peers
2) intermittent claudication is the defining symptom of PAD, traditionally affecting the calves but possibly including the thighs or buttocks
3) Pts w/ diabetes mellitus and peripheral neuropathy may not experience claudication in spite of severe PAD (always check pulse then neurological assessment (posterior tibial and dorsalis pedis pulse)
4) In addition to detecting PAD, the ankle-brachial index test is an important non-invasive predictor of CV events and total mortality
5) smoking cessation, exercise, and modification of other risk factors are the foundation for treating PAD

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17
Q

What should you do if a pt has PAD?

A

-vascular specialist
-nutrition
-physical therapy
-modified exercise routine
-check medications

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18
Q

What are the butt compartments?

A

superficial and deep compartments

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19
Q

What are the superficial butt muscles?

A

1) gluteus maximus
2) gluteus medius
3) gluteus minimus
4) tensor fasciae latae

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20
Q

What are the actions of the gluteus maximus muscle?

A

-Extend thigh
-Assist in lateral rotation
-Steadies thigh and assists in rising from sitting position

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21
Q

What is the vascular supply of gluteus maximus, gluteus medius, and gluteus minimus (and tensor fasciae latae)?

A

superior and inferior gluteal arteries (branch of internal iliac) and femoral arteries

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22
Q

What is the innervation of gluteus maximus?

A

inferior gluteal nerve (L5,S1,S2)

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23
Q

What are the actions of the gluteus medius and gluteus minimus muscle?

A

-Abduct and medially rotate thigh
-Keep pelvis level when ipsilateral limb is weight bearing during swinging motion

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24
Q

What is the innervation of gluteus medius and gluteus minimus (and tensor fasciae latae)?

A

superior gluteal nerve (L5, S1,S2)

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25
Q

What are the deep butt muscles?

A

1) piriformis
2) superior gemellus
3) obturator internus
4) inferior gemellus
5) quadratus femoris

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26
Q

What are the thigh compartments?

A

anterior, medial, and posterior compartments

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27
Q

What are the medial thigh muscles?

A

1) adductor longus
2) adductor brevis
3) adductor magnus
4) gracialis
5) obturator externus

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28
Q

What are the actions of the medial thigh muscles?

A

adducts the hip and plays minor role in hip flexion

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29
Q

What is the innervation of medial thigh muscles?

A

obturator nerve (L2-L4)

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30
Q

What is the vascular supply of medial thigh muscles?

A

obturator artery (branch of internal iliac artery)

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31
Q

What are the posterior thigh muscles?

A

1) semitendinosus
2) semimembranosus
3) biceps femoris (long and short heads)

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32
Q

What are the actions of posterior thigh muscles?

A

extend hip and flex knee

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33
Q

What is the innervation of posterior thigh muscles?

A

sciatic nerve

Tibial branch = semitendinosus and semimembranosus muscle

Common fibular branch = biceps femoris muscle

34
Q

What is the vascular supply of posterior thigh muscles?

A

perforating branches of profunda femoris artery

35
Q

What are the leg compartments?

A

anterior, lateral, posterior (superficial and deep)

36
Q

What are the lateral leg muscles?

A

fibularis longus and fibularis brevis

37
Q

What are the superficial posterior leg muscles?

A

1) gastrocnemius
2) soleus
3) plantaris

38
Q

What is the innervation of superficial posterior leg muscles?

A

tibial nerve (S1, S2)

39
Q

What are the deep posterior leg muscles?

A

1) popliteus
2) tibialis posterior
3) flexor digitorum
4) flexor hallicus longus

40
Q

What muscles are most commonly symptomatic with IC?

A

Calf muscles because the popliteal artery is the most commonly affected artery bc it branches off the femoral artery, the main artery in the thigh

41
Q

At what vertebral level does the aorta bifurcate into the common iliac arteries?

A

L4

42
Q

What artery is the origin for all arterial flow of the lower limb?

A

Abdominal aorta → common iliac arteries → external and internal iliac arteries

43
Q

Which arteries are usually palpable and where should you palpate each one?

A

Dorsalis pedis
-on the dorsum of the foot in the first intermetatarsal space just lateral to the extensor tendon of the great toe.
-Anterior tibial artery

Posterior tibial
-Behind and below the medial malleolus
-Posterior tibial artery

Popliteal
-Wrap your hand around your knee so your fingers are against the soft spot in the back of your knee. ‌Slowly press your fingers into this soft spot until you can feel your pulse - deep

Femoral
-located along the crease midway between the pubic bone and the anterior iliac crest - deep

44
Q

What are the major arteries of the lower limb?

A

Deep femoral artery and superficial femoral artery

45
Q

What artery supplies the muscles of the common locations of IC?

A

External iliac → femoral (superficial) → popliteal → anterior and posterior tibial arteries

46
Q

At what vertebral level does the IVC form from merging of its major tributaries?

A

-L5 - formed by union of R and L common iliac veins
-anterior to L5 vertebral level and inferior to bifurcation of aorta into R and L common iliac artery

47
Q

Identify the superficial veins, their origin, tributaries, course, termination and anatomical relationships

A

Great saphenous vein
-Starts from the medial marginal vein of foot, turns superficially along the length of the lower limb and empties into femoral vein
-Anterior to the medial malleolus → superficial to lower leg → up medial thigh - drains into femoral vein → external iliac → common iliac → IVC at L5

Small saphenous vein
-Begins where the dorsal vein from the 5th digit (smallest toe) merges with the dorsal venous arch of the foot and attaches to the great saphenous vein
-Travels posterior to the lateral malleolus → up posterior leg → distally, drains into popliteal vein behind the knee/in the popliteal fossa

48
Q

Identify the deep veins, their origin, tributaries, course, termination and anatomical relationships

A

Deep femoral vein

Origin = popliteal region

Course = posterior to deep femoral artery the entire length of the thigh → joins femoral vein → passes between adductor muscles → anastomoses with popliteal vein

Tributaries = inferior gluteal, medial, and lateral circumflex femoral veins and muscular branches

Termination = distally, anastomoses with popliteal vein

49
Q

What is the lumbar plexus and its major nerves?

A

T12-L4 anterior rami

Iliohypogastric n., ilioinguinal n., genitofemoral n., lateral femoral cutaneous n., femoral n., obturator n., lumbosacral trunk

50
Q

What is the sacral plexus and its major nerves?

A

L4-S4

Sciatic nerve (thickest diameter)

Superior gluteal n., inferior gluteal n., sciatic n., posterior cutaneous n., perforating cutaneous n., pudendal n.

51
Q

What nerve(s) supplies the muscles of the common locations of IC?

A

tibial nerve (S1,S2)

Gastrocnemius - lateral and medial heads: tibial nerve (S1-S2)
Soleus: tibial nerve (S1-S2)
Plantaris: tibial nerve (S1-S2)

*NOTE: no parasympathetic - only sympathetic: vascular and sweat glands

52
Q

A 20 year male patient with right LE intermittent claudication. For young patients, what could be the cause?

A

-PAES (popliteal artery entrapment syndrome)
-Cystic adventitial disease
-Fibromuscular dysplasia
-Takayasu’s arteries
-Buerger disease: TAOs → thromboangiitis obliterans
-Osteochondroma

53
Q

What is PAES (popliteal artery entrapment syndrome)?

A

-Condition (congenital) of the development of vascularization and results in muscular entrapment
-Numbness in the calves, can affect veins, lower leg cramping, blood clots of lower leg
-Gastrocnemius affected → compression of popliteal artery

54
Q

What is cystic adventitial disease?

A

-A cyst made of a mucus-like substance forms in an artery. This limits or blocks blood flow.
-Cystic adventitial disease (CAD) of the popliteal artery is a rare vascular disorder in which a mucin-containing cyst develops in the adventitial layer of the artery

55
Q

What is fibromuscular dysplasia?

A

-Abnormal cell growth in cell walls → stenosis of blood vessels
-Most common in women between 40-70 y/o

56
Q

What are Takayasu’s arteries?

A

Inflammation of larger blood vessels
Typically affects older females or Asians (20-40 y/o)

57
Q

What is Buerger disease: TAOs → thromboangiitis obliterans?

A

-A nonatherosclerotic, segmental, inflammatory disease that most commonly affects the small to medium-sized arteries and veins of the extremities (upper and lower)
-The inflammation can lead to blockages of the arteries of the lower portions of the arms and legs. These blockages can cause critical limb ischemia and/or claudication, rest pain and non-healing sores or ulcers, in the hands and/or feet.
-Smoking = high risk factor
-Most common in men; primarily asian

58
Q

What is osteochondroma?

A

-tumor
-Most common cause of lower leg pain
-Sessile = doesn’t have a stalk
-Directly from the bone

59
Q

Exercise-induced lower leg pain is a common complaint. For the majority of young adults, the pathology is musculoskeletal. These include…..

A

-MTSS (medial tibial stress syndrome)
-stress fractures
-tendinopathy and chronic calf tears

Pain will be elicited upon palpation, unlike most vascular conditions.

They do not cause ischemic symptoms.

CECS (chronic exertional compartment syndrome) can present with calf pain relieved by rest, with weakness and paresthesias. However, pulses are normal.

60
Q

Where is the MTSS (medial tibial stress syndrome) site of pain?

A

posteromedial tibial border

61
Q

For MTSS (medial tibial stress syndrome), is pain present at rest? Is there tenderness upon palpation? What is the pattern of pain?

A

no, yes

pain on exercise can last for minutes to hours after cessation

62
Q

Where is the stress fracture site of pain? Is pain present at rest? Is there tenderness upon palpation? What is the pattern of pain?

A

depends on site

no, yes

pain w/ impact activity

63
Q

Who is CECS (chronic exertional compartment syndrome) most common in? Male or female?

A

equal

64
Q

Where is the CECS (chronic exertional compartment syndrome) site of pain?

A

typically deep and/or anterior compartments

65
Q

For CECS (chronic exertional compartment syndrome), is pain present at rest? Is there tenderness upon palpation? What is the pattern of pain?

A

no, no

crescendo-descendo pain on exercise can last for seconds to minutes on cessation

66
Q

What is the normal origin of the medial head of the gastrocnemius?

A

Medial femoral condyle

Medial head originates from the posterior medial femoral condyle while the lateral head arises from the posterior lateral femoral condyle

67
Q

What is type 1 PAES (popliteal artery entrapment syndrome)?

A

popliteal artery running medial to the medial head of gastrocnemius

68
Q

What is type 2 PAES (popliteal artery entrapment syndrome)?

A

abnormal lateral attachment of medial head of gastrocnemius

69
Q

What is type 3 PAES (popliteal artery entrapment syndrome)?

A

accessory slip of gastrocnemius/fibrous bands arising from medial head of gastrocnemius

70
Q

What is type 4 PAES (popliteal artery entrapment syndrome)?

A

popliteal artery passing below popliteus muscle/ fibrous bands arising from popliteus

71
Q

What is type 5 PAES (popliteal artery entrapment syndrome)?

A

primarily venous entrapment

72
Q

A 67 y/o man presents to his physician complaining of sharp cramps and pains in his legs while exercising. The cramping is occurring in the calf area and occurs at any exercise intensity greater than walking at a moderate pace. He states that the pain is relieved by rest but starts again when he begins to exercise. Segmental blood pressure readings show a marked decrease in BP when measured at the calf. What combination of vascular flow and resistance characterizes the cramping period?

A

low blood flow, pre-capillary sphincters dilated

73
Q

The pain associated w/ PAES is typically located in the….

A

superficial posterior compartment of the leg

74
Q

Place the following location for intermittent claudication from the least to the most common:
1) thigh
2) butt
3) calf

A

2,1,3 (butt, thigh, calf)

75
Q

Which disease is typically associated w/ heavy smokers?

A

Buerger’s disease

76
Q

The major nerves of the thigh are the……

A

femoral nerve, obturator nerve, and sciatic nerve

77
Q

The inferior vena cava is formed by the union of the common iliac veins at the…..

A

L5

78
Q

Where does the small saphenous vein pass?

A

deeply into the popliteal fossa

79
Q

The posterior tibial artery is between the ____________ tendon and the posterior border of the ___________ _________

A

Achilles, medial malleolus

80
Q

What is the defining symptom of PAD?

A

IC

81
Q

Name 2 powerful vasodilators in an exercising muscle

A

hypoxia and metabolic waste

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