L14 - Peripheral Artery Disease

Question 1

3 causes of lower extremity occlusive disease

Answer 1

1. Atherosclerosis (lower extremity arterial block, smoking and diabetes are RF)
2. Embolism (cardiac, aneurysms, atheroemboli)
3. Misc (entrapment, adventitial cystic)

Question 2

Clinical presentation of LEOD

Answer 2

1. claudication (limping) - cramping, ache, fatigue, relieved by rest

Question 3

If there is rest pain with LEOD, where is it?

Answer 3

Rest pain if more advanced and distal in the foot across the metatarsals. Occurs at night and improved by gravity and movement
Ischemic pain at rest is typically distally in the foot across the metatarsal heads.

Question 4

T/F • Calf cramps at rest (e.g. night cramps) are suggestive of arterial ischemia.

Answer 4

FALSE - they are NOT suggestive

Question 5

What are the 6 Ps of acute ischemia?

Answer 5

○ Pain 
		○ Pallor 
		○ Paresthesia - abnormal sensation
		○ Paralysis 
		○ Pulselessness 
		○ Poikilothermia -  coolness

Question 6

Is this a physical exam of LEOD or aneurysm?

1. Appearance
2. Temperature
3. Pulses
4. Tissue Loss (gangrene, ulcers)

Answer 6

LEOD

pulses: Absent pulses certainly suggest arterial occlusive disease but other signs such as coolness, atrophic skin, dependent rubor or frank tissue loss (ulcer or gangrene) may also be present.

Question 7

Ankle-arm index test for LEOD.

1. Anklebrachial index 0.4-0.8 indicates ___________
2. Anklebrachial indices less than 0.4 indicates

Answer 7

1. claudication
2. rest pain or tissue loss

Normally the ankle pressure is higher than the arm pressure.

Question 8

Patients with diabetes may have calcified vessels causing falsely (low/high) measured ankle pressures due to the inability to compress the vessels with a cuff

Answer 8

high

Question 9

Pulse volume recordings are plethysmographic measurements of the volume changes associated with an arterial pulse and (are/are not) affected by calcification.

Answer 9

Are NOT

Question 10

Pressures may also be measured in a toe using photoplethysmography. These measurements may be helpful in patients with _________

Answer 10

calcified calf vessels since the digital vessels are often spared the severe calcification seen in patients with diabetes.

Question 11

Ddx of LEOD (3)

- which is specifically difficult to distinguish from?

Answer 11

1. Neurogenic claudication (spinal stenosis)
2. Neuropathy
3. Arthritis

Question 12

T/F • Imaging studies are usually not necessary to “diagnose” arterial occlusive disease.

Answer 12

True: diagnosis should be established by history, physical exam and supplemented by arterial pressure studies.
Imaging studies are obtained in patients when intervention is determined to be appropriate for planning the type of intervention

Question 13

Why doesn’t treatment of LEOD require intervention usually?

Answer 13

natural history of claudication is generally benign and a decision to intervene is not based on the anatomy bur rather on the degree of impairment of the individual.
Tx: RF modification, exercise, anti-platelet, medical

Question 14

Indications for Intervention (endovascular or open surgical therapy) in LEOD

Answer 14

1. Patients with true ischemic rest pain or tissue loss are often considered to have a “threatened” limb and therefore intervention may be appropriate.
2. Disabling symptoms

Question 15

T/F Endovascular methods are NOT durable in the proximal arterial segments (e.g. aorto-iliac) and the recurrence rate for infrainguinal endovascular interventions is very high.

Answer 15

FALSE: Endovascular methods ARE often durable in the proximal arterial segments (e.g. aorto-iliac) but the recurrence rate for infrainguinal endovascular interventions is very high.

Question 16

What can cause true aneurysms?

Answer 16

1. Atherosclerosis

2. Dissection

Question 17

True/False aneurysm?
The aneurysm is bound by all three layers of the vessel wall (intima, media and adventitia). The wall may be attenuated. Risk of rupture is proportional to the size of the aneurysm.

Answer 17

True Aneurysm

Question 18

True/False aneurysm?
Breach in the vessel wall such that blood leaks through the wall but is contained by the adventitia or surrounding perivascular soft tissue. A direct communication of blood flow exists between the vessel lumen and the aneurysm lumen through the hole in the vessel wall.

Answer 18

False Aneurysm - risk of rupture higher than true

Question 19

What can cause false aneurysms?

Answer 19

1. Trauma

2. Infection

Question 20

Breakdown of a graft to artery suture line is also referred to as a (true/pseudoaneurysm)

Answer 20

pseudo

Question 21

Component(s) of aneurysmal disease?

1. inherited
2. acquired
3. both

Answer 21

3 both

Question 22

Most common site of aortic aneurysms?

Answer 22

infrarenal aorta

Question 23

Most common site of peripheral arterial aneurysms is?

Answer 23

popliteal

Question 24

Most common site of visceral aneurysms?

Answer 24

splenic

Question 25

Which is false regarding the symptoms/signs of aneurysms?
A. asymptomatic typically
B. most common symptom presentation of aortic presentation is rupture
C. popliteal aneurysms commonly rupture

Answer 25

C. Popliteal aneurysms almost never rupture but can cause ischemia because of thrombosis or embolism.

Question 26

How can you diagnose a aneurysm?

Answer 26

1. Physical exam: palpate abdomen and popliteal area

2. Imaging (US, CT, arteriography - US most common and preferred)

Question 27

Indications for treating aneurysms (3)?

Answer 27

1. size (> or equal to 5cm)
2. surgical risk
3. life expectancy

Question 28

Define aneurysm

Answer 28

A ballooning and weakened area in an artery.

Question 29

What kind of treatment of aneurysm is this?

The aneurysm sac itself is not excised but is left in place with the graft placed inside the opened sac.

Answer 29

Open surgical aortic graft repair

Question 30

What kind of treatment of aneurysm is this?
Since the risk of a popliteal aneurysm is embolism or thrombosis the aneurysm is often bypassed and then ligated above and below.

This would never be done for an aortic aneurysm because of the continued risk of rupture.

Answer 30

Open surgical peripheral bypass/ligation

Question 31

What kind of treatment of aneurysm is this?
less morbid procedure than typical open aortic aneurysm repair.
The feasibility of this treatment is dependent on suitable anatomy i.e. adequate landing (seal zone) areas proximally and distally.

Answer 31

Endovascular stent-grafting

Question 32

3 Causes of carotid bifurcation disease

Answer 32

1. embolism - most common
2. hemodynamic
3. thrombosis

Question 33

Which is true regarding the clinical presentation of carotid bifurcation disease?
A. Transient Ischemic Attack/Stroke ( Hemispheric symptoms, Ocular, Rarely global)
B. Dizziness
C. syncope

Answer 33

A.

B and C almost never happen

Question 34

What is the best modality to evaluate the cervical carotid arteries when diagnosing carotid bifurcation disease?

Answer 34

Duplex scanning -high sensitivity and specificity

Question 35

When determining the degree of stenosis on arteriographic studies the ___________ should be used as the denominator for stenosis determination.

Answer 35

distal internal carotid

Question 36

Treatment of carotid bifurcation disease

Answer 36

• Medical
  
  • Risk-factor modification
  • Anti-platelet therapy

Question 37

Do symptomatic or asymptomatic patients with carotid bifurcation disease benefit greatly with intervention (carotid endarterectomy)?

Answer 37

Symptomatic

Question 38

Which has the higher risk of peri-procedural stroke in patients with carotid bifurcation disease?
carotid artery stenting (CAS) or carotid endarterectomy (CEA)

Answer 38

CAS - Advanced age is a particular risk factor for stroke associated with CAS but not CEA