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Vascular 2 > M5&6: Peripheral Arterial Part 1 & Indirect Testing > Flashcards

M5&6: Peripheral Arterial Part 1 & Indirect Testing Flashcards

1
Q

risk factors for PAD that can be related to life style

A 
HTN
diabetes
hyperlipidemia
smoking
obesity
physical inactivity
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2
Q

risk factors for carotid disease related to the heart and blood

A

homocysteine (a.a produced in liver)
high levels of C-reactive protein (made by the liver)
coronary artery disease
previous TIA or stroke

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3
Q

genetic and/or uncontrollable risk factors for carotid disease

A 
sex - male
age
hypercholesterolemia
genetic predisposition/fam Hx
patent foramen ovale
radiation
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4
Q

why is diabetes a risk factor for PAD

A
  • atherosclerosis is more common at a younger age in diabetics
  • high incidence of occlusive disease in the pop and tibial arteries
  • medial wall Ca ++ in the legs is common
  • high incidences of gangernous changes leading to amputation
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5
Q

skin changes seen w/ PAD

A 
pallor
rubor
dependant rubor
cyanosis
temperature changes
ulcers
gangrene
trophic changes
capillary refill time
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6
Q

describe rubor and dependant rubor

A

dark reddish colour or discolouration from dilated or damaged vessels

dependant: limb takes on pallor when elevated but is abnormally red with hanging dependant

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7
Q

why does cyanosis occur

A

[ ] of deoxygenated hemoglobin

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8
Q

where do ulcers usually form

A

over the tibial area

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9
Q

what do trophic changes refer to

A

shiny, scaly skin, thick toe nails, loss of hair… due to lack of nourishment

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10
Q

what is capillary refill time

why would it be increased

A

time it takes for colour to return to skin when pressure is applied and then released…. should return immediately

poor arterial blood supply

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11
Q

how are arterial pulses graded

what kind of pulse do aneurysms have

A

0-4 +
0 = no pulse
4 = bounding

bounding

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12
Q

what may be heard on auscultation w/ PAD

when is it not heard

how it it graded

A

bruits - abnormal frequency sound due to a significant stenosis…

if vessel is > 90% stenosed because trickle flow happens

1+ - 3+ (mild to severe)

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13
Q

describe claudication

cause

A

muscle pain that occurs w/ exercise and subsides with rest, intermittent and reproducible

lack of blood supply to a group of muscles

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14
Q

common sites for claudication

A

hip, thigh, butt, calf

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15
Q

if claudication is experienced, where is the disease location in reference to the affected muscle groups

A

disease is ALWAYS PROX to the affects muscle groups

(e.g. butt claud. = distal AO/iliac disease
thigh = distal external iliacs/CFA
calf = fem/pop disease)

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16
Q

describe ischemic rest pain

A

severe pain in the affected limb, usually affects the dorsum (top) of foot and toes, NOT relieved by rest

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17
Q

what does ischemic rest pain indicate

precursor to what

A

always an indicator of advanced multi-segment disease

limb loss unless theres treatment

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18
Q

when does ischemic rest pain usually occur during the day

why and what can relieve it

A

night…

limb is not dependent, relieved by lowering the foot or mildly exercising

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19
Q

what is the most sever symptom of PAD

A

necrosis

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20
Q

describe pseudoclaudication

A

pain caused by other factors (degenerative joint disease, spinal stenosis, herniated disc)

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21
Q

is pseudoclaudication reproducible w/ exercise testing

A

no

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22
Q

common patient HX w/ PAD

A 
exercise related claudication
rest pain
paralysis
paresthesia
poikilothermia
previous ulcerations/gangrene or therapeutic vascular procedures
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23
Q

most common location of obstructive atherosclerosis in LE

other common sites

A

SFA adductor canal/Hunters canal (distal SFA)… can be hard to see

bifurcations
pop artery

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24
Q

common cause of aneurysm in LE

common locations

A

trauma or atherosclerosis

AO (AAA)
femoral A
pop A

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25
common cause of subclavian aneurysms what can they cause
compress of the SA due to thoracic outlet syndrome embolization to the distal arteries in the hand
26
what is hypothenar hammer syndrome
aneurysms in the ulnar A due to using hand as hammer.....
27
diameter of A w/ an aneurysm how do we document them
-diameter of A increase by at least 50% - measure AP, outer wall to outer wall, in SAG and TRX - colour doppler
28
how does colour doppler help w/ an aneurysm
- helps to outline the thrombus | - shows to and fro flow along the outer wall of the aneurysm
29
why do we do peripheral arterial duplex testing
- look for stenosis or occlusion (can help w/ pre surgery/intervention) - evaluate bypass graft - look for aneurysm - follow up post surgery or to assess effectiveness of medical treatment
30
what pathology of the A wall can make a PA assessment hard
calcium deposits which will shadow
31
an ABI change of what value will warrant a LE, PA scan
decrease in ABI of > 0.15 compared to previous
32
common reasons for a PA scan of the UE
``` BP difference > 20 mmHg thoracic outlet syndrome evaluate prior to dialysis access cold sensitivity raynaud's syndrome ```
33
how should you document a suspected area of stenosis in the LE
- measure lumen reduction in 2D, especially w/ hemodynamically significant stenosis - document highest velocity + PW prox and distal to disease
34
why is it important to have colour gains set appropriately
if gain is too high, colour flow can obscure the true reduction of the lumen
35
how do we assess UE arteries
``` record 2D, colour and spectral images in SAG of: innominate A (for R side) prox SCA - probe supraclavicular dis SCA - probe infraclavicular Axillary A brachial A radial A (only spectral) ulnar A (only spectral) ```
36
normal PSV for UE arteries
SCA and AXA: 70-120 cm/s BRA: 50-120 cm/s RA and UA: 40-90 cm/s
37
what may be more important than velocity to determines disease in the UE
changes in the waveform
38
how far should you walk the SV proximal to a suspected stenosis what should you show distal to the stenosis
within 2 cm post stenotic turbulence and bruit if present
39
what velocity ratio can we use w/ PAD
V2/V1 : V2 is the max PSV of a stenosis, V1 is the PSV of the prox normal segment
40
normal lower extremity arterial waveforms have what characteristics
triphasic could be biphasic w/o any visualized stenosis... so could be classified as normal... more important is the discovery of CHANGES from triphasic to biphasic
41
should PSV be relatively uniform throughout an atria segment
yes
42
mean PSV in LE arteries
``` external iliac: 120 +/- 22 cm/s CFA: 114 +/- 25 cm/s SFA prox: 91 +/- 14 cm/s SFA dist: 94 +/- 14 cm/s pop A: 69 +/- 13 cm/s ```
43
describe a biphasic waveform
- strong forward flow in early systole/sharp upstroke - loss of flow in early diastole (no reversal) - decrease of late diastolic flow
44
describe a monophasic waveform
- decreased pulsatility and PSV - no reversed flow in late systole - may or may no have diastolic flow THINK TARDUS PARVUS - distal to severe stenosis
45
focal velocity increase of > or = what value indicates > 50% stenosis
> or = double of a prox norm arterial segment
46
focal velocity increase of > or = what value indicates > 70% stenosis
> or = triple of a prox norm arterial segment
47
what does a staccato waveform indicate
severe distal stenosis or occlusion
48
if an artery is completely occluded and hard to identify, what can you use to help
use the flow in an adjacent vein as a guide to identify the occluded
49
correlative tests for PAD
CTA MRA arteriography
50
medical treatment for PAD
``` change risk factors exercise antiplatelet medication anticoagulation thrombolysis ```
51
surgical treatment for PAD
``` bypass graft atherectomy resection for aneurysmal disease sympathectomy amputation ```
52
endovascular treatment for PAD
angioplasty stent intra-arterial directed thrombolysis
53
what is an ABI what does it specify
- non-invasive physiologic test that compared systolic BP at the ankles to the systolic BP of the brachial A - CW waveforms are recorded to support press information the resulting reduction in blood flow to the extremities at the ankle
54
why is an ABI referred to as indirect testing
youre not seeing the arteries directly
55
when will distal arterial flow and BP decreased significantly
when an arterial lumen is. narrowed to a critical level
56
when should ankle BP cuffs be placed
2-3 cm above the medial malleolus
57
which vessel in the foot is harder to compress and easier to find
PTA
58
is the signal of the DPA is damped, retrograde or absent, how should you change your probe position
move to the anterior ankle area, could search for an ATA signal
59
if you cant identify the DPA, which vessel do you sample instead where is it located
personal artery anterior to the lateral malleolus
60
which vessel in the foot is easy to compress and harder to find
DPA
61
do we take bilateral BRA pressures
YES
62
if bilateral arm press is different by > 20mmHg or if the waveforms are different, where should you look
vertebral for SCA steal syndrome
63
which brachial press do you use for the ABI calculation
highest
64
why is it good to record the ABI for each artery in the ankle
if you only take the highest, you could misrepresent or miss disease
65
avg ABI in supine for resting patient normal ABI
1.1 >1
66
when can medial calcification of arteries cause if ABIs are > 1.3 due to this condition, what should we do
falsely high ABIs toe pressures
67
in what type of patients do medial calcification occur
diabetics, patients on steroid medication for renal disease
68
normal toe/brachial pressure
> 0.75
69
ABI classifications
> 1.0 normal 0.9 - 1 minimal disease, aysmpt 0.5 - 0.9 claudication usually single level obstruction <0.5 rest pain, severe, multilevel disease <0.3 severe ischemia leasing to gangrene
70
when we are taking an ABI, at which location are we measuring the pressure
the location of the cuff, not the site of doppler interrogation
71
can you rely on a low pressure reading, but not a high one
yes
72
what happens to ABIs distal pressures w/ collateralization
collaterals will result in normal distal pressures and waveforms at rest
73
limitations of ABIs
bandages, trauma, surgery, ulcerations, grafts, ipsilateral side of mastectomy
74
function of exercise stress testing
determines the functional significance of disease by evaluating the arterial hemodynamics of the lower extremities
75
protocol for stress testing
pre-exercise BPs and ABIs re-measure BP and ABIs w/in first minute post exercise re-take the BPs and ABIs every 2 mins until ankle press returns to w/in 10 mmHg of the baseline press or for 6-12 mins (which ever comes first)
76
findings of a normal stress test
- little to no drop in ankle BP after 5 mins of exercise... < 20% change - decrease in post exercise BP should be < 20% of resting press and return to baseline w/in 3 mins post exercise
77
diagnostic criteria for post exercise BPs and ABIs + recovery time
< 3 mins RT: normal 2-6 mins RT: single level disease 6-12 mins RT: multi-level disease > 15 mins: severe occlusive disease
78
what changes in ankle BPs post-exercise indicate significant arterial obstruction
immediate decrease from baseline in post-exercise ankle BPs
79
can severity of PAD relate to the distant the patient can walk and absolute press drop
yes (more disease = less able to walk and greater press drop)

Vascular 2 (6 decks)

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