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Lec 23 Peripheral Vascular Disease Flashcards

1
Q

What is equation for blood flow [poiselle]?

A

Q = Ppir^4 / 8nL

Q = P/R

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2
Q

What factor has greatest impact on blood flow?

A

radius of the vessel

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3
Q

For two stenoses of same length and radius, what will higher flow rate due to pressure drop across the stenosis?

A

higher flow –> higher pressure drop

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4
Q

What happens to blood flow as area reduces?

A
  • speed of flow increases

- becomes more turbulent

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5
Q

What happens to flow of blood in systole? diastole?

A

systole: early = rapid flow of blood out then slows down
diastole: have recoil [neg flow] as heart fills up

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6
Q

What are some examples of high resistance arteries?

A
  • muscular arteries to arm, leg, external common carotid [to face muscles]
  • mesenteric arteries before you eat
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7
Q

What is difference in flow high vs low resistance vessels?

A

high resistance –> get flow mostly just with systole; very low flow with diastole

low resistance –> still get good flow with diastole = more essential organs

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8
Q

What are some examples of low resistance arteries?

A
  • internal carotids
  • vertebral arteries
  • renal arteries
  • mesenteric arteries after you eat
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9
Q

Are peripheral veins high or low resistance?

A

low resistance –> communicate directly with heart

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10
Q

hat are some characteristics of normal venous waveform?

A
  • respiratory phasicity
  • augmented with calf muscle compression
  • demonstrate valve competence [no retrograde flow w/ valsalva]
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11
Q

How do you detect valve competence?

A

ask patient to valvsalva

if you pick up blood flow = incompetent valve

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12
Q

What is peripheral artery disease?

A

atherosclerosis of aorta, iliac, and lower extremity arteries

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13
Q

What risks associated with peripheral artery disease?

A

regardless of symptoms it gives you a 3x increase risk in CV events

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14
Q

Who is at risk for getting peripheral artery disease?

A
  • people who smoke and have diabetes

- people with chronic kidney disease

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15
Q

What are clinical manifestations of peripheral artery disease?

A

intermittent claudication or critical limb ischemia

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16
Q

What is intermittent claudication?

A

pain or fatigue in calf/thigh/buttock or low back that occurs with exertion and relieve by rest

location of symptoms correlates with one level below disease/obstruction

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17
Q

What are symptoms of critical limb ischemia? what exacerbates/improves?

A

symptoms:

  • pain or parasthesia in lower extremity at rest
  • ischemic uclerations
  • gangrene
  • exacerbated by leg elevation [or when supine] = elevation pallor
  • relieved by hanging foot over the side of bed = dependent rubor [filled w/ blood]
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18
Q

What is leriche triad?

A

classic triad of symptoms related to aortic and iliac atherosclerosis

  • bilateral butt and thigh claudication
  • impotence
  • global atrophy of extremity
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19
Q

What is most frequent location of peripheral artery disease?
A. aorto-iliac
B. femor-popliteal
C. tibial-peroneal?

A

femoro-popliteal is most common

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20
Q

What is prognosis of aorto-iliac peripheral artery disease? Where do you feel the pain?

A

collateral typically well developed –> good prognosis for revascularization with high patency

feel the pain in thigh

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21
Q

What is order of patency rates in revascularization procedures for peripheral artery disease of the following vessels:
A. aorto-iliac
B. femoro-popliteal
C. tibial-peroneal

A

patency decreases as you go down

Aorto-iliac > femoro-popliteal > tibial-peroneal

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22
Q

What is prognosis of femoro-popliteal peripheral artery disease? where do you feel the pain?

A

collateral determine course
intermediate patency rate with revascularization

thigh/calf pain

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23
Q

What is prognosis of tibial-peroneal peripheral artery disease? where do you feel the pain?

A

associated with DM
low graft patency rates

calf/foot pain

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24
Q

How do people with PAD initial present?

A
  • asymptomatic
  • atypical leg pain
  • claudication
  • very rare critical limb ischemia
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25
What is 1 yr prognosis of critical limb ischemia?
50% alive w/ 2 limbs 25% amputation 25% CV mortality
26
What is 5 yr prognosis of pts with peripheral artery disease?
mostly fine at 5 yrs 20% have non-fatal CV event 15-30% dead
27
What physiologic testing to detect PAD?
- ankle/brachial or toe/brachial index - pulse volume recordings - segmental limb pressures - continuous wave doppler
28
What is purpose of ankle-brachial index? how do you calculate?
to detect pressure differences between arms and legs that tell you if there is an obstruction between the two calculate left ABI take highest systolic BP of L posterior tibial or L dorsalis pedis = L ankle BP take highest brachial systolic BP between R and L [ex. if R = 160 and L = 120 use 160 for all calculations] L ABI = L ankle BP / highest brachial BP
29
What is a normal ABI? obstructed?
normal = 0.9-1.4 < 0.9 = mild obstruction 0.4-0.7 = moderate obstruction < 0.4 = severe obstruction > 1.4 = calcified vessel
30
What happens if ankle-brachial index > 1.4
means the vessel is calcified so its not really a valid reading need to do the toe brachial instead
31
How do you calculate toe-brachial index? normal value?
great toe pressure / brachial pressure | normal > 0.7
32
When do you use toe-brachial index instead of ankle-brachial index?
in setting of vessel non-compressibility [BP > 250 mmHg] or ABI > 1.4 b/c smaller vessels are not affected by calcification
33
What is association ankle-brachila index and mortality?
pts with low ABI = much higher mortality than normal pts with > 1.4 have slightly higher mortality than normal
34
How do you measure arterial pulse volume recordings?
leave BP cuff inflated | measure volume displacement of blood in each wave form
35
What is use of segmental BP?
identify location of disease [>20 mmHg drop]
36
What is duplex US?
non invasive imaging for elavaluating hemodynamics and detect stenosis > 50%
37
What is use of MR angiography in peripheral artery disease?
may over estimate degree of stenosis | limited in setting of metal, intravascular stents/coils
38
When can you not use MR and CT angiography?
limited in renal failure
39
Does MR angiography under or over estimate degree of stenosis?
over estimate
40
What is limitation of CT angiography in peripheral artery disease?
limited in evaluation of calcified vessels
41
What are goals of peripheral artery disease treatment?
decrease cardiac events/death | improve symptoms/function
42
What are measures to decrease cardiac events and death in PAD?
- stop smoking - control BP: ACE inhibitor - control lipids: statins - antiplatelets: aspirin/clopidogrel - regular exercise - control diabetes
43
What medications do you give in peripheral vascular disease?
- ACE inhibitor to control BP - statins to control lipids - aspirin/clopidogrel = decrease risk clots - cilostazol = improve symtpoms
44
What are measures do increase function/symptoms in PAD?
walking program = walk to point of pain repeatedly --> develop collateral circulation and build up tolerance drugs: cilostazol = decreases symptoms; mech unknown revascularization if doesn't respond to med therapy
45
What are 2 major causes of acute arterial occlusion?
- in situ thrombosis --> atherosclerotic plaque rupture | - embolism from heart or aorta
46
What care the 6 causes of acute arterial occlusion?
- in situ thrombosis - embolism - arterial trauma - vasculitis - hypercoagulable state - severe venous thrombosis [phlegmasia cerulea dolans]
47
What are the 6 P symptoms of acute limb ischemia?
- pulseless - pain - paralysis - parasthesia = tingling - pallor - poikilothermia = can't maintain body temp
48
What time frame for acute limb ischemia?
symptoms for less than 2 weeks
49
What is class I limb ischemia? treatment?
``` class I = no rest pain palpable/audible pulses ``` not immediately treated
50
What is class II limb ischemia? treatment?
``` class II = ischemic rest pain, ankle pressure < 50 mmHg mild-moderate sensory and motor deficits ``` treat: salvagable limb --> promptly revascularize
51
What is class III limb ischemia? treatment?
class III = absent doppler signals, paralysis, muscle rigor treat: not viable limb --> amputation needed
52
What is buerger's diease? who gets it?
segmental inflammation of medium sized arteries and veins; involves distal vessels of upper and lower extremities. eading to thrombosis and vaospasm men > women age < 40 yrs TOBACCO = cause/necessary for progression of disease
53
What are signs of buerger's disease? how do you differentiate from other causes?
triad: - superficial thrombophlebitis - raynaud's [vasospasm] - distal arterial occlusion --> claudication corkscrew collaterals; alternating areas of stenosis/occlusion with normal arterial segments; lack of atherosclerosis in proximal vessels; 2 or more extremities involved rule out others by: negative test for autoimmune markers; exclude atherosclerotic embolus as cause
54
What is treatment for buerger's diease?
stop smoking + amputation
55
What should you think if you see corkscrew collaterals?
probably buergers
56
What is raynaud's phenomenon?
``` vasospasm of digital arteries triphasic color response - fingers/toes blanch to white = ischemia - cyanosis = blue - blood flow resumes = rubor/red ``` colors may be accompanies by numbness, parasthesias, or pain of affected digits brought on by cold exposure, emotional stress
57
How do you diagnose primary raynauds? who gets it?
- bilateral, present at least 2 yrs without secondary cause - onset 15-40 yrs [younger than secondary] - women > men - some spontaneously improve, others progress
58
What are symptoms of venous thrombosis?
leg pain/swelling erythema palpable cord
59
What are varicose veins?
dilated tortuous superficial veins often in lower extremities; most common in saphenous veins family history, women > men due to intrinsic weakness of vessel wall from increased intraluminal pressure
60
What is difference primary vs secondary varicose veins?
primary = originate in superficial system; associated with pregnancy, standing, obestity seoncdary = abnormality in deep venous system is the cause; associated with deep venous insufficiency/occlsion
61
Where does DVT usually occur?
calves in popliteal or higher
62
Where does superficial thrombophlebitis usually occur?
in saphenous
63
What is virchows triad?
puts you at risk of increased blood clot: 1 stasis of blood 2 endothelial injury 3 hypercoagulable state
64
What is phlegmasia cerulea dolans?
most severe form of deep vein thrombosis --> limb gets blood in but can't come out get compartment syndrome with increasing fluid blue painful leg --> venous gangrene massive red/purple swelling, diminished pulses limb and life threatening emergency!
65
What are some signs of DVT on ultrasound?
- dilated non-compressible veins with incomplete filling | - lack of respiratory phasicity and flow augmentation
66
What are the 2 major consequences of DVT?
- pulmonary emobolism | - postphlebetic syndrome
67
Is DVT more common in proximal vs distal veins? which are more likely to cause PE?
- distal veins more likely to develop DVT - proximal veins at more risk of PE ``` proximal = iliac, femoral, popliteal distal = deep muscular veins ```
68
What is postphlebitic syndrome?
postphlebitic syndrome = chronic venous insufficiency - damaged venous valves / persistent occlusion by DVT --> leads to chronic leg swelling, stasis pigementation, skin ulceration blood and fluid backflows into periphery with valsalva [increased intra-thoracic P] or even at rest = get reversal of flow; less venous return to heart
69
What are symptoms of pulmonary embolism?
SOB, chest pain, hemoptysis, tachycardia, hypoxia
70
What happens in massive PE?
have RV strain with hemodynamic compromise --> syncope, cardiac arrest, resp failure, cor pulmonale
71
What happens in submassive PE?
have RV strain with hemodynamic stability and normal BP
72
What is chronic thromboembolic pulm HTN?
if get repeated pulm emboli over time get HTN
73
What are symtpoms of chronic venous insufficency?
swelling, pain, skin flaking, ulceration, varicose veins inverted champagne bottle inflammation and fibrosis of lower 2/3 of leg
74
What is stasis cellulitis?
often mistaken for infectious cellultiis does not respond to antibiotics = warm, red tender swollen leg; inflammatory process related to venous stasis and excess interstitial fluid treat with compression
75
What are 3 causes of swollen limb?
- chronic venous insufficiency - lipedema - lymphedema
76
What is lipedema?
- dispropotionate fat deposition in lower half of body but torso relateively normal - spares foot = ankle cut off sign - bilateral and symmetric; non pitting; tender; soft - "fat pad sign" anterior to lateral malleoli
77
What is lymphedema?
begins distally; involves toes and feet buffalo hump = dorsum of foot stemmers sign = pathognomonic = inability to pinch the skin at the base of 2nd toe early have pitting; late = firm and non-pitting at risk for recurrent cellulitis

Cardio Exam 2 (19 decks)

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