Miller Peripheral Vascular Disease

Question 1

Major risks for PAD?

Answer 1

• htn
• hyperlipidemia
  
  • low HDL
  • high LDL
• DM
• CKD
• Cigarette smoking

Question 2

“Big picture” of atherosclerosis?

Answer 2

• LDL cholesterol excess
• inflammation
• endothelial dysfunction
• continued accumulation

Question 3

What are the symptoms of intermittent claudication?

Answer 3

• Fatigue
• discomfort
• cramping
• pain in muscles

Question 4

What is intermittent claudication the hallmark of?

Answer 4

Chronic ischemia in PAD

Question 5

What are the symptoms of acute arterial occlusin?

Answer 5

• cold painful and pale extremity with diminished absent/pulses
• weakness
• impaired sensation
• 6 P’s
  
  • Poikilothermia
  • pain
  • pallor
  • pulsellessness
  • paralysis
  • paresthesia

Question 6

How long does skeletal muscle tolerate ischemia?

Answer 6

4-6 hours

Question 7

How will a leg of a person with PAD chronic ischemia look?

Answer 7

• shiny skin with no hair and muscle atrophy
• can have non healing wound or gangrene

Question 8

What is the first step in the diagnosis of PAD?

Answer 8

• ABI
  
  • systolic bp at brachial artery and ratio of highest systolic pressure in each leg
  • >0.9 is good
  • <0.9 bad

Question 9

If an ABI is abnormal what is the next step?

Answer 9

• Arterial US
• CT angiography
• Angiography

Question 10

How do you treat chronic ischemia seen in PAD?

Answer 10

• exercise
• antiplatelet therapy
  
  • aspirin or clopidogrel
• statin
• ACEI or ARB for those with htn

Question 11

For patients with lifestyle limiting claudication, what treatment is the next step?

Answer 11

• Revascularization
  
  • angioplasty/stent
  • endarterectomy
  • bypass grafting

Question 12

Complications of PAD?

Answer 12

• Critical limb ischemia
• hanging limb over side of bed decreases pain
  
  • creates rubor
  • elevate feet creates palor
• non healing ulcers

Question 13

What are the two manifestations of VTE?

Answer 13

• DVT
• PE

Question 14

Risk factors for VTE?

Answer 14

• Strong (10-50x)
  
  • Major surgery trauma, plaster cast and cancer
• Moderate (2-10x)
  
  • genetics
  • acquired such as lifestyle, medications, non hemological conditions

Question 15

What is Virchows triad?

Answer 15

• Hypercoagulability
• Changes in flow such as stasis and turbulence
• Endothelial dysfunction

Question 16

How do we prevent VTE?

Answer 16

• Risk for DVT and PE are assessed when patients are hospitalized
  
  • if at risk given anticoagulants or mechanical methods to keep muscles moving

Question 17

Management of DVT?

Answer 17

• initial treatment of heparin or direct oral anticoagulants is for 5-10 days
• Long term tx is with warfarin for 3-6 months
• Extended treatment is >6 months

Question 18

Complications of DVT?

Answer 18

• PE

Question 19

What are signs of post thrombotic syndrome? What does it increase the risk for?

Answer 19

• Leg pain, heaviness, vein dilation, edema, skin pigmentation, and venous ulcers
• Increases risk for recurrent DVT and chronic venous insufficiency

Question 20

Diagnosis of chronic venous disease?

Answer 20

• Pain, leg heaviness, aching, swelling, skin dryness, rightness, itching, irritation, muscle cramps
• Dilated veins, leg edema, skin induration hyperpigmentation and skin ulceration
  
  • large shallow superficial ulceration