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Peripheral Arterial Disease > Lower Extremity Arterial Disease: General Considerations > Flashcards

Lower Extremity Arterial Disease: General Considerations Flashcards

1
Q

What is the role of the vascular specialist as it relates to PAD?

A
  1. Recognize the extent of lower extremity ischemia
  2. Quantify the extent of local and systemic disease
  3. Determine the degree of functional impairment
  4. Identify and control risk factors
  5. Establish a comprehensive treatment program
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2
Q

What is the symptom presentation for the patient with intermittent claudication?

A

Aching or fatigue in calves, thigh or buttock while walking. This is alleviated with rest.

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3
Q

Describe the pathophysiology of the pain sensation experienced by patients with PAD.

A

The pain sensation results from ischemic neuropathy involving small unmyelinated A delta and C sensory fibers and a local intramuscular acidosis from anaerobic metabolism enhanced by the release of substance P.

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4
Q

Do asymptomatic patients with ABIs

A

Yes!
These asymptomatic patients may have significant impairment of leg function when tested objectively. These patients may have poor medical conditions and functional capacity.

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5
Q

Describe the disease location for patients with intermittent claudication.

A

It is usually single level disease but may be multi-level affected the muscle groups distal to the site of hemodynamically significant stenosis.

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6
Q

What are the 3 major patterns of arterial obstruction?

A
  1. Inflow disease
  2. Outflow disease
  3. Combination of the two
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7
Q

What does inflow disease refer to?

A

Infow disease refers to lesions in the suprainguinal vessels most commonly the infrarenal aorta or iliac arteries and leads to buttock or thigh claudication.

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8
Q

What does outflow disease refer to?

A

Outflow disease consists of occlusive lesions in the lower extremity arterial tree below the inguinal ligament from the CFA to the pedal vessels

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9
Q

Popliteal and tibial disease is most likely seen in what type of patients?

A

older patients
diabetics
renal failure
longterm corticosteroid use

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10
Q

List all the nonatherosclerotic causes of intermittent claudication.

A
  1. CIA: Endofibrosis (in competitive cyclists)
  2. Popliteal artery: adventitial cystic disease, popliteal artery entrapment syndrome, popliteal artery aneurysm, peripheral emboli, FMD
  3. Vascular tumor
  4. Vasculitis: Thromboangiitis obliterans, Takayasu’s arteritis, arteritis
  5. Trauma and radiation injury
  6. Genetics: Pseudoxanthoma elasticum, coarctation of the aorta
  7. Chronic compartment syndrome
  8. Thrombosis of a persistent sciatic artery
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11
Q

Describe the pathophysiology of critical limb ischemia.

A

Arterioles are maximally dilated and insensitive to vasorelaxing/vasoconstricting factors because of chronic exposure to vasorelaxing factors. These arterioles have decreased wall thickness and due to their dilatation, this leads to edema and aggravated by a dependent limb. Chronic ischemia leads to changes in struction and function of endothelial cells, and coupled with platelet activation and leukocyte adhesion results in microthrombi formation in the capillaries. All of these factors leads to impaired tissue oxygen exchange at the capillary level.

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12
Q

Describe the clinical presentation of CLI.

A

Patients typically have ischemic rest pain, tissue loss with gangrene or ulceration representing a reduction in tissue perfusion below resting metabolic requirements

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13
Q

What are the hemodynamic criteria for the diagnosis of CLI?

A

ABI

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14
Q

Describe non-diabetic arterial ulceration.

A

A non-diabetic arterial ulcer is characterized by a shallow, nonhealing pallid erosion of the skin in the distal foot and presents as an aching or burning pain. Skin repair is hampered by inadequate tissue perfusion, oxygenation and cellular replication.

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15
Q

What are the 3 categories of diabetic ulcers?

A
  1. Neuropathic
  2. Ischemic
  3. Neuroischemic
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16
Q

What is an angiosome?

A

An angiosome is an anatomic unit of tissue (consisting of skin, subcutaneous tissue, fascia, muscle, and bone) fed by a source artery and drained by specific veins

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17
Q

What is the risk of tissue gangrene in diabetics vs non diabetics with CLI?

A

40% in diabetics

9% in nondiabetics

18
Q

What is the ABI classification for PAD?

A

> 1,4: incompressible
1-1.4: normal
0.9-0.99: borderline

19
Q

Who should we screen for PAD?

A

ACC/AHA 2011 recommends screening all patients greater than 65 years of age or anyone over 50 years of age with a history of smoking or diabetes

20
Q

What is the prevalence of PAD in the US?

A

8-12 million people affected

21
Q

What are the risk factors associated with PAD?

A 
Age
Sex
Ethnicity (black women, Hispanic women)
HTN
DLP
DM
Smoking history
Renal failure
22
Q

Define the metabolic syndrome.

A 
3 or more of the following:
BP>130/85
TGs>150
HDL110
BMI>30 or waist circumference >102 cm in men and > 88cm in women
23
Q

What is the overall medical risk of those with asymptomatic PAD?

A

Longitudinal studies demonstrate that patients with asymptomatic PAD have higher risks of mortality and morbidity from cardiovascular events compared to age-matched controls without PAD - therefore elevated risk of MI, stroke and death

24
Q

What is the impact of asymptomatic PAD on the female sex?

A

Females were more likely to have faster functional decline - inability to perform 6 min walk test continuously, higher incidence of mobility loss and had faster declines in walking capacity compared to men.

25
Q

What is the strongest predictor of mortality in patients with asymptomatic PAD?

A

Functional and exercise capacity is the greater predictor of death with each exertional MET achieved being associated with 18-20% reductions in all-cause and cardiovascualr mortality

26
Q

How many patients detiorate significantly after the dx of intermittent claudication?

A

25%
6-9% within the first year of diagnosis
2-3% per year therafter

27
Q

What is the impact of smoking on progression of PAD in non-diabetics?

A

Of the non-diabetic patients, 8% progress to CLI of those who stopped smoking vs 79% of those who continued smoking

28
Q

What is the risk of amputation in patients with intermittent claudication?

A

5% over a 5 year period

29
Q

Describe the Edinburgh Arterial Study?

A

Looking at symptomatic PAD and found that there was no statistically significant drop in ABI over 5 years of observation. Nonetheless they have higher morbidity and mortality compared to standard controls

30
Q

What other diseases is PAD associated with?

A

CAD

CVD

31
Q

What did the REACH registry describe about the incidence of cardiovascular death MI or stroke at 1 year with atherosclerotic arterial disease?

A
  1. 5% for patients with CAD
  2. 5% for CVD
  3. 4 % for PAD
32
Q

Describe the natural history of CLI.

A

40% develop limb loss
20% die within 6 months
50% 5 year mortality
70% 10 year mortality

33
Q

Risk factors for atherosclerosis:

A 
Age
Race/ethnicity
Male gender
Smoking
HTN
DLP
Diabetes
CRF
Hyperhomocysterinemia
Hyperfibrinogenemia
Hypercoagulability
Obesity
34
Q

What is the initial hemotologic evaluation in claudicants?

A

CBC (WBC, platelets)
Fasting blood glucose or Hgb A1C
Cr
Fasting lipid profile (total chol, HDL, LDL, TGs)
Urinalysis (proteinuria)
Nutritional assessment (albumin and prealbumin)
CRP

35
Q

What are secondary hematologic evaluations based on suspicion?

A 
Thrombin, prothrombin time
Activated partial thromboplastin time
Protein C and S assay
Factor V Leiden
Anti-thrombin III activity
Lupus anticoagulant
Anticardiolipin antibody
Heparin-induced platelet antibodies (PF4)
Platelet adhesiveness, aggregability
Fibrinogen, Plasminogen levels
36
Q

List the clinical predictors of increased perioperative cardiovascular risk

A 
Unstable coronary syndromes (ACS)
Unstable angina or servere angina 
Recent MI (7 days-1 month)
Decompensated heart failure (NYHA IV)
High-grade atrioventricular block:
-Mobitz II atrionventricular block
-Third-degree atrioventricular block
Significant arrhythmias
-Symptomatic ventricular arrhythmias
-Supraventricular arrhythmias (including afib) with uncontrolled ventricular rate (HR>100)
-Symptomatic bradycardia
-Newly recognized ventricular tachycardia
Severe valvular disease
-Severe AS (MP gradient>40 mmHg or AV area
37
Q

Whats the percentage of people with PAD having >50% or >70% carotid stenosis

A
  1. 2% in >70% CAStenosis

17. 6% in >50% CAStenosis

38
Q

What is the BASIL trial

A

Bypass Vs. Angioplasty in Severe Ischemia of the Leg
Showed that patients who had bypass initially with an intact limb for more than 2 years lived longer than those with angioplasty first.

39
Q

What were the variables in the grading system in BASIL

A 
tissue loss
BMI
Cr
CAD
Ankle pressure
Smoking
Bollinger Score
40
Q

Describe the treadmill testing for exercise ABIs

A

Treadmill at 12% incline and walking at 3.5km/hr until claudication sx present

41
Q

A positive exercise ABI is:

A

A drop in 20 mmHg post exercise for more than 3 minutes

Peripheral Arterial Disease (1 decks)

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