L1 - Peripheral Vascular Disease Flashcards
Peripheral “flow” diseases can effect what 3 different systems/structures? Which one of the 3 is the focus of most discussion?
Peripheral vascular disease = Peripheral Artery Disease (PAD) or Peripheral Venous Disease (PVD)
Peripheral Lymphatic Disease (PLD)
Arteries
With reference to diseases, what does peripheral mean?
Extremity
What is it called when the lymphatic system is occluded?
Lymphadema (type of PLD)
What peripheral vascular disease is associated with pulmonary embolism?
DVT (Deep venous thrombosis)
What is it called when you have inflammation of veins due to a clot?
Phlebitis (type of PVD)
What results when there are valvular problems in peripheral vascular system?
Venous Insufficiency (retrograde flow & congestion)
Varicose veins (enlarged torturous veins)
What symptoms point towards aneurysm? What stage of the disease is present when symptoms first present?
Diverse, depends on location
Mainly pain, pulsatile mass & renal dysfunction
Later stage of disease
Atherosclerosis starts as what?
Fatty streak
What makes up atherosclerotic plaques?
Lipid
Cholesterol
Ca
Cellular debris
What layer(s) of the vessel is/are atherosclerotic plaques generally deposited?
Intima
What must be present for an aneurysm to be “true”?
All 3 layers must be involved
What causes the symptoms related to atherosclerosis?
Narrowing of artery lumen & decreased in oxygen delivery
Late stage. Overall vessel diameter increases before lumen is occluded. Need a large plaque to start changing size of lumen
Risk factors for Atherosclerosis/PAD?
Diabetes Smoking Dyslipidemia Age Male FHx HTN Obesity African American Hypercoagulable
What does “cardiovascular equivalent” mean with regards to risk factors for vascular disease?
Diabetics are so prone to vascular disease (atherosclerosis), that you essentially treat them as if they have had an MI in the past even if that isn’t the case
What medical condition was stressed as one that drastically increases a persons risk of atherosclerosis? What about element of the social history?
Diabetes
Smoking
Generally speaking, Cerebral Artery Disease occurs where?
Aortic arch or intracranial vessels (vessels between heart & brain)
Mainly where common carotid splits into internal & external
Atherosclerosis can lead to what vascular disorders?
Cerebral art disease/stroke
Coronary art disease/MI
PAD
Aneurysm
Causes of cerebral artery disease?
Atherosclerosis
Non-atherosclerotic causes (dissection or arterial dysplasia)
What is the diagnosis if patient presents with aphasia, hemiparesis, paresthesia, poor cognition or weakness that lasts for LESS than an hour?
TIA
What is the diagnosis if patient presents with aphasia, hemiparesis, paresthesia, poor cognition or weakness that lasts for MORE than an hour?
Stroke (CVA = Cerebral Vascular accident)
Patient with normal CT has had abnormal neurological signs for 2 hours. Diagnosis?
Stroke (NOT TIA) cuz too long
CT doesn’t show small lacunar strokes, need MRI
Mini-stroke is called what?
TIA
Main difference between TIA & stroke?
TIA is reversible & stroke is irreversible
The buzzwords “curtains drawn” correlate with what?
Amaurosis Fugax
What is it called when you have one sided partial or full blindness lasting seconds to minutes?
Amaurosis Fugax
Lose upper visual fields
Treatment for Amaurosis Fugax?
Surgery
Really serious so almost immediately qualify for surgery. The episode itself is transient, but it is a sign of future problems
Stroke & TIA are types of what?
CVA
How is CVA severity determined?
Carotid Duplex Ultrasound
Guidelines for surgical treatment for CVD?
If stroke, TIA or Amaurosis Fugax & 50% occlusion
If asymptomatic & 80% occlusion
Surgical techniques for CVD?
Debate
“Newer” stent vs. “older” endarterectomy (scrape out plaque)
Absolute risk reduction associated with surgery for carotid occlusion >50% in males? Number needed to treat?
Stroke risk decreases from 2% –> 1% per year
19
Absolute risk reduction associated with surgery for carotid occlusion in females?
Way less than males. Usually don’t do surgery on females
The buzzwords “pain out of proportion to exam” means what?
No focal tenderness or rigidity, but in horrible pain
Mesenteric Ischemia
Severe ab pain following big greasy meal. Diagnosis?
= post-prandial pain –> mesenteric ischemia
Trying to shunt more blood to GI system to help with digestion, but some sort of occlusion prevents this
Likely treatment for Mesenteric Ischemia?
Surgery cuz pretty severe
Result of untreated Mesenteric Ischemia?
Bowel death
List of symptoms that may be present with Mesenteric Ischemia?
Nausea/vomiting Flatulence Bloody stool Diarrhea Elevated Lactate levels (hypoxia --> anaerobic metab --> lactic acid)
What is functional PVD?
Less common type of PVD where there is some sort of transient spasm that limits flow
Usually an exaggeration of normal dilation/constriction
Does not involve structural defect
Examples of functional PVD?
Raynauds
Acrocyanosis (persistent cyanosis)
What is Organic PVD?
Structural changes to the vessel (inflammation or tissue damage) cause occlusion
Examples of Organic PVD?
Atherosclerosis/PAD
Buerger’s Disease (progressive inflammation & clotting in peripheral vessels)
Smokers who lose limbs most likely have what disease?
Buerger’s Disease
Smoking is a huge risk factors for disease
Leg pain that is alleviated by walking uphill or sitting down. Diagnosis?
Spinal stenosis
Cramping, tightness, pain or fatigue in the calf, leg, thigh or butt that is effort induced?
Claudication
Can have a diverse presentation in anything from the hip down
Patient has leg pain while walking around the mall. Keeps having to rest for about 10 minutes. Diagnosis?
Claudication
Why does claudication only cause pain during exercise?
During rest the occluded vessel can supply enough blood. During exercise more blood needs to be shunted to the muscle, but the occlusion prevents this –> ischemia –> pain
What % of patients with Claudication present with textbook classic symptoms? What % has no leg pain?
Only 10%
50% have non-classical leg pain
40% have no leg pain
Older disabled female presents with leg fatigue and no pain. Diagnosis?
“atypical” claudication
2/3 patients like this have no leg pain
Change in prevalence of PAD by age?
Increases dramatically with age
What % of patients with PAD are on correct therapy?
20-30%
Most goes unrecognized or is incorrectly treated
Best treatment for PAD?
Lifestyle changes, specifically smoking cessation
When encouraging males to make lifestyle changes, what symptom of PAD should be stressed to “scare” them into taking action?
Erectile dysfunction
Symptoms of PAD?
Claudication LE pain LE numbness LE fatigue LE heaviness ED
Findings for acute leg ischemia?
6 Ps
Pain Palor Paresthesia (tingling/numbness) Paralysis Pulselessness Poikilothermia (inability to maintain core temp)
Patient with signs of PAD still has a pulse. Suspected severity?
Still could be bad. Loss of pulse is one of the later stage signs
Exam findings for PAD?
Bruits Absent or deminished pulses Cold extremities Long cap refill Skin changes HTN & abnormal fundoscopic exam (risk factors not cause)
Location of effected vascular lesion if have Butt/hip pain?
Aortoiliac (ab aorta or iliac arteries)
Location of effected vascular lesion if have thigh pain?
Aortoiliac (ab aorta or iliac arteries) or Common femoral (continuation of external iliac before gives off deep femoral)
Location of effected vascular lesion if have upper calf pain?
Superficial femoral (superficial branch of common femoral after deep femoral is given off)
Location of effected vascular lesion if have lower calf pain?
Popliteal (extension of superficial femoral)
Location of effected vascular lesion if have foot pain?
Tibial or Peroneal (extension of popliteal)
How do you evaluate severity of Claudication?
Ankle-Brachial test
First line test (easy, cheap)
UE & LE BP compared (use ultrasound to amplify sound)
Meaning of Ankle-Brachial Index results?
>.9 = nl .6-.9 = mild (still concerning) .4-.6 = Moderate <.4 = severe claudication
PAD labs?
Basically testing for risk factors
Lipid panel HbA1c CMP (liver, kidney & electrolytes) CRP (non-specific inflammation) Test for coagulapathies
What imaging tests are for PAD?
CT or MRI angiography, usually in anticipation of surgery but sometimes diagnostic
Goals for someone with PAD?
Quit smoking HbA1c < 6.5% HTN < 130/80 LDL < 70 45 min of walking per day
PAD pharm treatment?
HTN drugs (ACE, beta blocker)
Statins
Diabetic meds
Anti-platelet meds (aspirin, plavix if aspirn intolerence, Cilostazol if severe)
Treatment for Claudication with ABI around .75?
Is not critical limb ischemia
Risk factor modification with 3 mo follow up. If persistent use intervention
Treatment of Claudication with ABI aroung .35?
= Critical limb ischemia
Surgery!
Presents with SOB & leg pain. Diagnosis?
DVT with pulmonary embolism
What is CVA?
Cerebral Vascular Accident = Stroke = cerebral artery disease
Frail 95 yo patient has 80% blockage of cerebral vessel. Surgery?
No, they won’t survive surgery
What is PAD?
Subset of atheroscelrosis that is not in the coronary vessels (coronary art disease) or in the brain (cerebral artery disease)
Really bad PAD is called what?
Critical Limb Ischemia (poor wound healing, infections, gangrene …)
What is a type of chronic vascular inflammation?
Atherosclerosis
Atherosclerosis occurs in what type of vessel?
artery
What is an example of peripheral venous disease?
Phlebitis
What causes Amaurosis Fugax?
Some sort of occlusion in ophthalmic artery
Type of TIA, temporary
Trace pathway of blood from ab to foot? What areas are affected when these arteries are occluded?
ab aorta + iliac art (butt/hip pain) –> Common femoral (thigh/leg) –> superficial femoral (upper calf) –> Popliteal (lower calf) –> tibial/peroneal (foot)
5 year mortality for claudication patients who continue to smoke?
50%
What is the relationship between PAD and smoking?
increases PAD risk sevenfold
increases progression of disease
Earlier Onset of disease
What is a synonym for PAD?
Atherosclerosis
PAD is really a subset of atherosclerosis not in the heart or brain
What type PAD called if infection, poor wound healing, gangrene or rest pain is present?
Critical limb ischemia
How do you determine severity of CAD?
Echo
What type of PAD presents with nausea/vomiting, diarrhea and flatulence?
Mesenteric Ischemia
What types of surgical options are there for PAD?
Stent
Intravascular thrombolytics
Angioplasty
Bypass graft
What drugs should be avoided for somebody with PAD?
Avoid vasoconstriction drugs (Psuedoephederine)
Effort induced Claudication should be relieved with how much rest?
10 min
What is the number needed to treat with anti-platelet drugs in PAD?
45
