PAD

Question 1

Epidemiology of Peripheral Atherosclerosis

Answer 1

-MC site is femoropopliteal artery
-peak incidence of claudication is in 60s and 70s
-increased r/o death (systemic dz so it is happening in coronary a. as well)

Question 2

RFs of peripheral atherosclerosis

Answer 2

-cigarette smoking
-DM
-Dyslipidemia
-HTN
-FH
-hyperhomocysteinemia (associated with damage to arterial walls)
-CKD

Question 3

PAD: Sx

Answer 3

1. INTERMITTENT CLAUDICATION distal to clot:
   -discomfort, fatigue, or heaviness in affected leg while walking that resolves w/ rest
2. REST PAIN (indicates more severe dz):
   -pain worse w/ leg elevation/lying down (BF working against gravity)
   -less pain while sitting and dangling legs
   -may develop skin ulceration, necrosis (cell death), and gangrene (skin tissue death)

Question 4

PAD: PE

Answer 4

-decreased/absent peripheral pulses (doppler if can’t palpate)
-bruits (iliac)(audible abn flow around plaques)
-Buerger test (elevate pt lef to look for skin color change)
-Foot pallor
-Signs of chronic ischemia (subcutaneous atrophy, hair loss, coolness, pallor, cyanosis, dependent rubor (extra red when legs dangle))
-Critical ischemia (petechiae, fissures, ulceration, gangrene)
-Check for sensory and motor loss!!!

Question 5

if a pt has rest pain, ulcers, and gangrene what should you do

Answer 5

refer to vascular surgeon

Question 6

PAD: Dx tests

Answer 6

-ABI <1.0 (works well in mild-moderate dz; severe ischemia pts may not tolerate test d/t pain)
-US
-MRA or CTA

Question 7

PAD: Tx

Answer 7

-stop smoking
-ASA
-exercise (typically supervised)
-aggressive lipid-lowering therapy (high-intensity statins)
-lower BP to normotensive range (B-blocker)
-aggressive tx of DM
-Naftidrofuryl or Cilostazol (vasodilators) if pts do not improve w/ exercise & risk modification
-in more severe cases: angioplasty, bypass, amputation
-refer to vascular surgery

Question 8

MC cause of Acute arterial occlusion

Answer 8

cardiac embolism

Question 9

Acute arterial occlusion: Acute Sx

Answer 9

loss of pulses
severe limb pain
paresthesia (loss of sensation)
distal motor weakness

Question 10

Acute arterial occlusion: Dx test

Answer 10

angiography

Question 11

Acute arterial occlusion: Tx

Answer 11

urgent revascularization (thrombolysis or surgery) w/in 3h

Question 12

Atheroembolism (Cholesterol crystal embolism)

Answer 12

-debris from friable (fragile) plaques (usu in aorta) embolize to small distal arteries, causing obstruction; may follow invasive testing or trauma

Question 13

Atheroembolism (Cholesterol crystal embolism): S/S

Answer 13

TIAs
renal failure
skin changes (levido reticularis = pink & blue net-like appearance of skin, “blue toe syndrome”)
bowel ischemia

*often all show up at same time

Question 14

Atheroembolism (Cholesterol crystal embolism): Dx tests

Answer 14

skin or muscle bx
-TEE (to look for plaque in aorta)
-CT
-MRI

Question 15

Atheroembolism (Cholesterol crystal embolism): Tx

Answer 15

Medical therapy:
-ASA
-statin
-tx HTN
-tx DM
-stop smoking

*no surgical option

Question 16

thromboangiitis obliterans (Buerger Disease)

Answer 16

-inflammation that affects arteries and veins in extremities causing constricted BF
-men <50yo that SMOKE (anything)

Question 17

thromboangiitis obliterans (Buerger Disease): S/S

Answer 17

claudication
rest pain
ulcers
white fingers (lack of BF), blue fingers (lack of O2)

Question 18

thromboangiitis obliterans (Buerger Disease): Tx

Answer 18

most pts do well if they stop smoking
-smoking cessation decreases changes of needing amputation

Question 19

Raynaud’s Phenomenon: S/S, Dx, Tx

Answer 19

episodic vasospastic ischemia of the digits
-affects F>M
-often autoimmune & may be accompanied by other autoimmune conditions

Sx:
-digital blanching, cyanosis, and rubor
-may have stinging pain

Dx: often “clinical”

Tx: only tx if sx bother pt
-avoid cold exposure
-drugs: Nifedipine (CCB), prazosin (alpha-blocker)
-surgery: sympathectomy (impair sympNS by removing ganglion)