PAD Medical

Question 1

1. Define PAD from an anatomical standpoint.

Answer 1

structural atherosclerotic narrowing of any non-coronary vessel which limits blood flow to the limbs

Question 2

1. Define PAD from the functional standpoint.

Answer 2

arterial narrowing causing a mismatch between organ supply and demand causing intermittent symptoms of claudication and/or tissue ischemia

Question 3

2. Discuss the prevalence of PAD and associated risk of coronary artery disease.

Answer 3

In a primary care population defined by age and common risk factors, the prevalence of PAD was approximately one in three patients

prevalence increases with age

Question 4

3. Name the single most important, modifiable cause of PAD.

Answer 4

tobacco use (dose dependent) causes a 10x increase in relative risk

Question 5

3. What factors besides smoking put a patient at risk for PAD?

Answer 5

DM (increases 2-4x due to inflammation of endothelial), dyslipidemia (elevated total cholesterol and increased TG)
HTN (esp. regarding stroke)
inflammatory mediators
age, gender and ethnicity
obesity and physical inactivity

Question 6

3. What is the stratification for individuals “at risk” for lower extremity PAD?

Answer 6

less than 50, with DM and one additional factor
50-60 yo with smoking or DM
70 yo or older
known atherosclerotic coronary, carotid or renal artery disease

Question 7

What is claudication and what causes it?

Answer 7

dull aching muscular discomfort induced by exercise and relived by rest caused by muscle ischemia

atypical presentation include fatigue, heaviness, dysesthesia or cold sensation

Question 8

4. Discuss the elements of a vascular focused hx. and PE.

Answer 8

bilateral arm BP
cardiac exam
palpation for abdominal aneurysm
auscultation for bruits
exam of legs and feet
pulse exam (carotid, radial/ulnar, femoral, pop., dorsalis pedis and posterior tibial)

Question 9

Describe the scale used to describe pulse (0-3).

Answer 9

0- absent
1-diminished
2-normal
3-bounding

Question 10

5. What is the standard test used to assess PAD?

Answer 10

resting ankle-brachial index measurement

Question 11

What is the procedure for preforming an ABI?

Answer 11

performed with patient supine

all pressures measured with an arterial doppler and appropriately sized blood pressure cuff

systolic pressures will be measured in the R/L brachial arteries followed by R/L ankle

Question 12

What is an ABI?

Answer 12

ratio of higher brachial systolic pressure and the higher ankle systolic pressure for each leg (give an ABI score for each leg)

Question 13

6. What ABI is diagnostic for PAD?

Answer 13

greater or equal to 0.9

.91-.99 borderline
.41-.9 mild/moderate
less than .4 severe disease

Question 14

5. What are important characteristics of a ultrasonogoraphy read-out that are important?

Answer 14

the shape can help you ID turbulent flow and velocity can also be important with obstruction

this modality can diagnosis anatomic location and degree of stenosis

Question 15

5. What is MRA and what are its benefits?

Answer 15

magnetic resonance angiography (has replaced contrast arteriography for PAD diagnosis)

benefits: no ionizing radiation, no iodine contrast
(some limitations with claustrophobia, pacemaker or obesity)

Question 16

5. Name one other imaging technology beyond MRA that can be used in PAD and what are its downsides?

Answer 16

CTA- Computed tomographic angiography

requires iodinated contrast and ionizing radiation

Question 17

Name two different causes of renal artery stenosis.

Answer 17

atherosclerotic etiology (risk factors similar for atherosclerosis)
fibromuscular dysplasia (congenital)

Question 18

How could location of plaque help you differentiate between athersclerotic plaques v. fibromuscular dysplasia?

Answer 18

atherosclerotic: proximal segment

fibromuscular dysplasia: mid to distal segment

Question 19

What is the size of an abdominal aortic aneurysms relative to normal diameter? What is the danger of this disease?

Answer 19

diameter +50%, dilation greater than 2x the size of a more proximal artery

with risk of dissection, mortality is high (once rupture happens, 75-90% death)

Question 20

Where would you most likely find an aortic aneurysm? (abdominal v. thoracic)

Answer 20

abdominal are more common then thoracic aneurysms, especially in men

screening should be considered for those with a family history or smoking history

Question 21

3. Discuss the prevalence and significance of carotid disease.

Answer 21

third leading cause of death in the US, 50% of patients with a stroke will have a second stroke within 5 years if untreated

Question 22

What are the two different kinds of stroke and what is their mutual outcome.

Answer 22

ischemic (clot) 85%
hemorrhagic (bleeding)

both result in brain cell damage

Question 23

7. What are the two major goals in treating patients with PAD?

Answer 23

limiting poor limb outcomes (improve walking, prevent progression of disease/amputation)

reducing CV morbidity and mortality (decrease non-fatal stroke and decrease fatal MI and stroke.

Question 24

Why is walking so important with CAD.

Answer 24

getting the patient walking will encourage collateral arteries and activity level can help to decrease overall risk

Question 25

8. What are major parts of treating the underlying PAD?

Answer 25

``` smoking cessation anti platelet therapy address hyperlipidemia and HTN control diabetes get active, lose weight ```

Question 26

7. What are indications for angioplasty/ stent in PAD?

Answer 26

persistent limiting claudication, preventing work or ADL rest pain tissue loss/non healing ulcers abdominal aorta or renal artery severe disease carotid artery severe disease not in lower exterminates, bypass or vein/synthetic graft may be indicated