PAD - Peripheral Artery Disease Flashcards
Define PAD
Chronic insufficiency of arterial blood supply to the limbs due to vessel stenosis or occlusion
What is the main cause of PAD?
Give 2 other rare causes?
Atherosclerosis
Fibromuscular Dysplasia
Vasculitis (takayasu, buerger’s)
Radiation-induced
Give 10 RFs for PAD
Modifiable:
Smoking
HTN
Diabetes
Hypercholesterolaemia
Obesity/physical inactivity
Radiation-induced
Non-modifiable:
Male
Age >55
A.fib
Hypercoagulable state (anti-phospholipid)
Fam hx of atherosclerotic disease
Hyperhomocysteinemia
Vasculitis (Buerger’s, Takayasu)
Fibromuscular dysplasia
What are the 2 main presentations via PAD? Define them
Intermittent claudication - Muscular pain in calves/buttocks exacerbated by exercise, relieved by rest
Critical limb ischaemia - Rest pain >2 weeks - pain in forefoot when lying flat, relieved by hanging leg over side of bed +/- ulcers gangrene necrosis
What is Lyriche syndrome?
Give the triad
Occlusion at the bifurcation of the aorta at L4 causing triad of:
1) Buttock/thigh claudication
2) Absent/reduced femoral pulse
3) Erectile dysfunction
What is the general presentation of PAD
6 Ps:
Pain:
Intermittent claudication - Muscular pain in calves/buttocks exacerbated by exercise, relieved by rest
Critical limb ischaemia - Rest pain >2 weeks - pain in forefoot when lying flat, relieved by hanging leg over side of bed +/- ulcers gangrene necrosis
Pallor
Perishingly cold
Pulselessness
Paraesthesia
Paralysis
What is meant by Atrophic changes of PAD
Smooth Shiny skin
Hairless
Ulcers
What is meant by tissue loss in PAD?
Ulcers, gangrene, necrosis
What is the main tool used to grade PAD? Go through it
Fontaine Classification:
I - Asymptomatic
IIa - Intermittent claudication >200m
IIb - Intermittent claudication <200m
III - Rest pain (hanging leg)
IV - Tissue loss (ulcers, gangrene necrosis)
How would you differentiate between a spinal pathology and PAD when taking a history
PAD: Relieved by stopping, worse when going uphill
Spine: Relieved by stopping + sitting down and better when going uphill
What should be elicited in a hx of PAD?
SOCRATES for pain
When? differentiate between chronic, acute on chronic, or acute limb ischaemia
Intermittent claudication: How far? rest relieves? Pain at rest? At night? hanging leg?
!! If rest relieves do you they need to stop and sit or just stop for a bit and can continue?
Notice swelling?
Skin: Change of colour? Feet cold? Sores on legs that cannot heal? Painful!!?
Weakness of leg
Numbness
Previous Amputations
+ Previous history of ALI
+ Rule out DVT (warm to touch swelling)
RF for PAD: Smoking, cholesterol, !!diabetes, exercise, Family hx, Diagnosed with any genetic or autoimmune conditions
RF for Ischaemic limb: + A.fib, COCP/HRT, congenital thrombophilia, recent immobility, cancer
What are your differentials for PAD?
Acute/chronic limb ischaemia/PAD/Leriche syndrome
Spinal stenosis
Osteoarthritis
Nerve entrapment (disc protrusion, bone metastasis, fracture)
DVT (venous claudication)
Trauma
Vasculitis (Buerger’s, Takayasu)
How would you differentiate between an arterial and venous ulcer?
How is a venous ulcer treated?
Conservative:
4-layered PROFORE dressing
Leg elevation
Venous support stockings
Medical:
Antibiotics if infection
Surgical:
Skin graft
Varicose vein surgery once ulcer healed to reduce recurrence rate
What imaging is the best overall for detecting stenosis/occlusion of an artery casing PAD?
Duplex US
What directly relevant investigations would you order for a patient with suspected PAD?
For imaging and procedure, combine them and list them in order of use and importance
Bedside: ABG + ECG (A.fib)
Bloods: Routine + thrombophilia screen
Procedures and imaging:
1) ABPI +!toe pressures
2) Duplex US to assess for stenosis/occlusion
3) CT/MR angiogram
4) DSA - Digital subtraction angiography
which is preferred between CT and MR angiogram in PAD?
MR angiogram
Discuss ABPI as you would in a long case
Mention toe pressures + image
Calcification in diabetes and CKD
Take me through the conservative management of PAD
Take me through the LL arterial supply
What muscle does the superficial femoral artery pass near to?
What arteries supply the different compartments of the leg?
Symptom relief can be prescribed to patients with PAD. These drugs are not covered by the HSE and do not improve outcomes.
State the name of the 2 drugs and their MOA
Cilostazol: Phosphodiesterase inhibitor
Pentoxifylline: Xanthine derivative
both cause to vasodilation (cilostazol better)
Give me a study to reference in PAD.
CLEVER study which compared outcomes in groups with supervised eercise training and other groups with stenting but not supervised exercise. The study concluded that those with supervised exercise had similar outcomes to those with stenting
What medications are given to anything vascular?
why are these 2 meds given to anything vascular?
Antiplatelet therapy
+ Statin
These two enhance angiogenesis, vascular motor tone and have an anti-inflammatory effect together
The anti-platelet therapy is used more for preventing MI and stroke rather than PAD itself. IT DOES NOT DISSOLVE THE CLOT (thats what alteplase is for)
What is the medical management of PAD
List the surgical options for the treatment of PAD
Endovascular: Balloon Angioplasty +/- stenting
Surgical:
Endarterectomy
Bypass Procedure
Amputation
Briefly describe angioplasty
1) General anaesthesia + Seldinger technique
2) Balloon covered with expandable metal stent passed
3) Balloon compresses plaque => widens lumen
4) Stent implanted
Briefly explain what is an endarterectomy
Procedure to remove the atherosclerotic plaque
Involves surgically incising the artery and directly excising the plaque or intima layer
Closure via dacron or bovine patch
What are the 2 types of grafts used in bypass procedures
List the benefits of each
Synthetic:
Better at handling pressure
+ Longer patency
GSV graft:
Reduced risk of infection
+ Better patency in smaller vessels
+ Honours: Can arterialise after being exposed to pressure
What can synthetic grafts used in bypass procedures (PAD) most commonly made of (2)?
Dacron
PTFE
List the most common types of bypasses and the graft type used for each
Axillo-Bifem (or just fem): Synthetic
Aorto-Bifem: Synthetic
Fem-Fem: Synthetic
Fem-Pop: Above knee = Synthetic, Below knee = GSV
Fem-Distal: GSV
Just another note: They can be separated also into anatomical and extra-anatomical (common sense)
If they cannot harvest the GSV for a bypass, what other veins may be used?
SSV
Cephalic (UL)
Basilic (UL)
What bypass would you use for a patient with Leriche Syndrome?
Obviously it depends where the occlusion is
Aorto-Bifem
Axillo-Bifem
What is the full management of PAD? Do it ttek
