PAD vasc boards ACC-SAP and Cath-SAP Flashcards
atypical claudication sx
heaviness or weakness with stairs/ ambulation (this is seen in ~30%)
definition of intermittent claudication (4 parts)
discomfort cramping or aching in calves, thighs buttox that
- comes on with exertion
- improves with rest
- reproducible
ddx (4) of acute onset leg pain
- athero/thromboemboli (AF,AAA)
- plaque ruputure
- dissection
- other embolic conditions –> infectious, metastatic
hx signaling location of PAD lesion
isolated calf? –> SFA
Buttox and calf –> aorto iliac
How do ABI
higher DP or PT over higher arm right or left
when do TBI
abi > 1.4
when do exercise
0.9 to 1.4 with sx’s
what direction is arterial flow shown in ultrasound
R to L (higher to lower)
abn u/s findings the basics (4) and examples
- easiest increased systolic velocity (ie > 125 cm/s)
- increased end diastolic velocity (ie > 40 in ICA) off baseline
- Aliasing
- smaller diameter
65% stenosis in the CIa which is a class 1 indication –> asx
statin
PAD recommendations for antiplt rx guildlines (give level of recommendations I, IIa, IIb)
1a. ASA alone or plavix alone class Ia in symptomatic pts with PAD (monotherapy)
IIa - asx patients with PAD antiplt (ASA or plavix is reasonable) < 0.9)
IIb. asx with b/l abi 0.91-0.99 uncertain benefit ot antiplatelet
statins also Ia
Note riva 2.5 bid + asa will be IIa soon likely! given compass pad
data for Ia recommendation for statins
heart protection study in lancet 2002 24% RR reduciton < 0.00001 for patients with mi, chd, pad, stroke or dm (note DM data was extremely powerful)
what was the heart protection study.
simvastatin in patients with some form of vascular dz (MI, HF, CVD, DM) and showed a 24% relative risk reduction
it was in lancet in 2002.
NOACs or coumadin in PAD?
III? what about compass? –> now showing benefit. eickelboom JW
Compass PAD –> riva 2.5 bid + asa 81with HR of 0.72 p0.005. this is going to change everything. patients with pad will be on riva +asa as a class I however there is a price of excess bleeding. This will change how we manage PAD (compass PAD lancet 2018)
compass pad
asa + riva 2.5 in secondary prevention of PAD with HR of 0.72 and p of 0.0005 vs asa alone.
what about rx to reduce claudicatoin
cilostazole (cant use with CHF) class I. pentofxifyline is class III
moa of cilosazole
grade of recommmendation
warning
who would you use it in?
phospdiaesterase III inhibitor
class I
cant use in CHF.
no one.
class I recs for sx pad (claudication)
statin asa or clopidogrel (riva may be coming) cilostazole although we dont use it structured exercise (supervised over unsupervized when availibe class Ia vs. IIa)
when is an endovascular intervention Ia?
IIa?
IIb?
Ia? lifestyle limiting aorto-iliac claudication
IIa? fempop
infrapop
class III recommendatio regarding endovascular intervention in claudicaiton
class III - endovascular procedures should not be performed in patients with pad soley to prevent progression to CLI
grade this statement “endovascualr procedures should not be performed in patients with PAD soley to prevent progression to CLI
class III harm.
surgery for claudication when class I, IIa, III (2)
I vein over prostethic dacron grafting ehn feasible
IIa. surgical procedures are reasonable as revasc option for patients with lifestyly limiting claudication with inadequate response to GDMT and technical factors suggesting advantages over endovascular procedures.
III. harm femoral tibial a. bypass with prosthetic grafts should NOT BE USED FOR CLUAIDICATION
III surgical procedures for claudication shouldbt be performed to prevent progressoin to CLI
5 year patecy for aortoilica or aortofemoral bypasses
90%
CLI endovascular rx recs if have nonhealing wounds or gangrene
what about CLI 2/2 rutherford IV (rest pain)
angiosome directed endovascualr rx in patients with CLI and nonhealing wounds/ gangrene
Class I,
IIa
IIb -