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Cardio Exam 2 > Lec 23 Peripheral Vascular Disease > Flashcards

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
Q

What is 1 yr prognosis of critical limb ischemia?

A

50% alive w/ 2 limbs
25% amputation
25% CV mortality

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26
Q

What is 5 yr prognosis of pts with peripheral artery disease?

A

mostly fine at 5 yrs
20% have non-fatal CV event
15-30% dead

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27
Q

What physiologic testing to detect PAD?

A
  • ankle/brachial or toe/brachial index
  • pulse volume recordings
  • segmental limb pressures
  • continuous wave doppler
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28
Q

What is purpose of ankle-brachial index? how do you calculate?

A

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

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29
Q

What is a normal ABI? obstructed?

A

normal = 0.9-1.4
< 0.9 = mild obstruction
0.4-0.7 = moderate obstruction
< 0.4 = severe obstruction

> 1.4 = calcified vessel

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30
Q

What happens if ankle-brachial index > 1.4

A

means the vessel is calcified so its not really a valid reading
need to do the toe brachial instead

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31
Q

How do you calculate toe-brachial index? normal value?

A

great toe pressure / brachial pressure

normal > 0.7

32
Q

When do you use toe-brachial index instead of ankle-brachial index?

A

in setting of vessel non-compressibility [BP > 250 mmHg] or ABI > 1.4

b/c smaller vessels are not affected by calcification

33
Q

What is association ankle-brachila index and mortality?

A

pts with low ABI = much higher mortality than normal

pts with > 1.4 have slightly higher mortality than normal

34
Q

How do you measure arterial pulse volume recordings?

A

leave BP cuff inflated

measure volume displacement of blood in each wave form

35
Q

What is use of segmental BP?

A

identify location of disease [>20 mmHg drop]

36
Q

What is duplex US?

A

non invasive imaging for elavaluating hemodynamics and detect stenosis > 50%

37
Q

What is use of MR angiography in peripheral artery disease?

A

may over estimate degree of stenosis

limited in setting of metal, intravascular stents/coils

38
Q

When can you not use MR and CT angiography?

A

limited in renal failure

39
Q

Does MR angiography under or over estimate degree of stenosis?

A

over estimate

40
Q

What is limitation of CT angiography in peripheral artery disease?

A

limited in evaluation of calcified vessels

41
Q

What are goals of peripheral artery disease treatment?

A

decrease cardiac events/death

improve symptoms/function

42
Q

What are measures to decrease cardiac events and death in PAD?

A
  • stop smoking
  • control BP: ACE inhibitor
  • control lipids: statins
  • antiplatelets: aspirin/clopidogrel
  • regular exercise
  • control diabetes
43
Q

What medications do you give in peripheral vascular disease?

A
  • ACE inhibitor to control BP
  • statins to control lipids
  • aspirin/clopidogrel = decrease risk clots
  • cilostazol = improve symtpoms
44
Q

What are measures do increase function/symptoms in PAD?

A

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
Q

What are 2 major causes of acute arterial occlusion?

A
  • in situ thrombosis –> atherosclerotic plaque rupture

- embolism from heart or aorta

46
Q

What care the 6 causes of acute arterial occlusion?

A
  • in situ thrombosis
  • embolism
  • arterial trauma
  • vasculitis
  • hypercoagulable state
  • severe venous thrombosis [phlegmasia cerulea dolans]
47
Q

What are the 6 P symptoms of acute limb ischemia?

A
  • pulseless
  • pain
  • paralysis
  • parasthesia = tingling
  • pallor
  • poikilothermia = can’t maintain body temp
48
Q

What time frame for acute limb ischemia?

A

symptoms for less than 2 weeks

49
Q

What is class I limb ischemia? treatment?

A 
class I = no rest pain
palpable/audible pulses

not immediately treated

50
Q

What is class II limb ischemia? treatment?

A 
class II = ischemic rest pain, ankle pressure < 50 mmHg
mild-moderate sensory and motor deficits

treat: salvagable limb –> promptly revascularize

51
Q

What is class III limb ischemia? treatment?

A

class III = absent doppler signals, paralysis, muscle rigor

treat: not viable limb –> amputation needed

52
Q

What is buerger’s diease? who gets it?

A

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
Q

What are signs of buerger’s disease? how do you differentiate from other causes?

A

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
Q

What is treatment for buerger’s diease?

A

stop smoking + amputation

55
Q

What should you think if you see corkscrew collaterals?

A

probably buergers

56
Q

What is raynaud’s phenomenon?

A 
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
Q

How do you diagnose primary raynauds? who gets it?

A
  • bilateral, present at least 2 yrs without secondary cause
  • onset 15-40 yrs [younger than secondary]
  • women > men
  • some spontaneously improve, others progress
58
Q

What are symptoms of venous thrombosis?

A

leg pain/swelling
erythema
palpable cord

59
Q

What are varicose veins?

A

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
Q

What is difference primary vs secondary varicose veins?

A

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
Q

Where does DVT usually occur?

A

calves in popliteal or higher

62
Q

Where does superficial thrombophlebitis usually occur?

A

in saphenous

63
Q

What is virchows triad?

A

puts you at risk of increased blood clot:
1 stasis of blood
2 endothelial injury
3 hypercoagulable state

64
Q

What is phlegmasia cerulea dolans?

A

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
Q

What are some signs of DVT on ultrasound?

A
  • dilated non-compressible veins with incomplete filling

- lack of respiratory phasicity and flow augmentation

66
Q

What are the 2 major consequences of DVT?

A
  • pulmonary emobolism

- postphlebetic syndrome

67
Q

Is DVT more common in proximal vs distal veins? which are more likely to cause PE?

A
  • distal veins more likely to develop DVT
  • proximal veins at more risk of PE
proximal = iliac, femoral, popliteal
distal = deep muscular veins
68
Q

What is postphlebitic syndrome?

A

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
Q

What are symptoms of pulmonary embolism?

A

SOB, chest pain, hemoptysis, tachycardia, hypoxia

70
Q

What happens in massive PE?

A

have RV strain with hemodynamic compromise

–> syncope, cardiac arrest, resp failure, cor pulmonale

71
Q

What happens in submassive PE?

A

have RV strain with hemodynamic stability and normal BP

72
Q

What is chronic thromboembolic pulm HTN?

A

if get repeated pulm emboli over time get HTN

73
Q

What are symtpoms of chronic venous insufficency?

A

swelling, pain, skin flaking, ulceration, varicose veins

inverted champagne bottle inflammation and fibrosis of lower 2/3 of leg

74
Q

What is stasis cellulitis?

A

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
Q

What are 3 causes of swollen limb?

A
  • chronic venous insufficiency
  • lipedema
  • lymphedema
76
Q

What is lipedema?

A
  • 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
Q

What is lymphedema?

A

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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