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Cardiology > Peripheral Arterial Disease > Flashcards

Peripheral Arterial Disease Flashcards

1
Q

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

A

anatomical definition of PAD

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2
Q

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

A

functional definiton of PAD

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3
Q

what are the classifications of PAD?

A

Lower extremity arterial disease
* typically known as PAD
* pain in the legs with walking or at rest (severe)

Abdominal
* aortic aneruysm
* renal artery
* mesenteric

Cerebral vascular (carotid)
microvascular

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4
Q

What are common causes of PAD?

A
  1. tobacco (single most important modifiable cause
  2. diabetes mellitus
  3. dyslipidemia
  4. hypertension
  5. inflammatory mediators (homocysteine, fibrinogen, c-reactive protein, lipoprotein (a), renal disease
  6. age, gender (male) and ethnicity (african american)
  7. obesity and physical inactivity
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5
Q

who is at risk for lower extremity PAD?

A
  1. Age < 50 years. with diabetes and one additional risk factor (smoking, lipidemia, hypertension etc.)
  2. age 50-69 years and history of smoking or diabetes
  3. age 70 years and older
  4. known atherosclerotic coronary, carotid, or renal artery disease
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6
Q

Symptoms of PAD?

A
  • analogous to angina pectoris
  • intermittent limb claudication (dull aching muscular discomfort induced by exercise and relieved by rest, often at discrete threshold of work)
  • atypical features common (fatigue, heaviness, dysesthesia or cold sensation)
  • not nocturnal cramps
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7
Q

what are indications to perform an ankle-brachial index (ABI) measurement?

A

Obtain history of walking impairment and/or limb ischemic symptoms
*obtain a vascular review of sx: leg discomfort with exertion; leg pain at rest; non-healing wound; gangrene
*Then review: no leg pain, atypical leg pain, classic claudication, chronic critical limb ischemia, acute limb ischemia-
*ALL of the above are reasons to perform ABI

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8
Q

How do you perform the ABI exam?

A
  1. Perform with the patient resting in the supine position
  2. all pressures are measured with an arterial doppler and appropriately sized cuff
  3. systolic pressures will be measured in the right and left brachial arteries followed by the right and left ankle arteries
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9
Q

how do you calculate the ABI?

A

ABI= Ankle systolic pressure/ higher brachial artery systolic pressure

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10
Q

What are the value ranges of the ABI?

A

1.00-1.29= normal
0.91-0.99= boderline, low normal
0.41-0.90= mild to moderate disease
< 0.40 = severe disease
> 1.30 = noncompressible

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11
Q

when is an exercise ABI indicated? what does it assess? what would support a PAD diagnosis?

A
  • Indicated when the ABI is normal or boderline but symptoms are consistent with claudication
  • assesses functional capacity (patient symptoms may be discordant with exercise capacity)
  • An ABI fall post exercise supports a PAD diagnosis
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12
Q

Aterial duplex ultrasound testing of the extremities can be used for candidates for?

A
  1. endovascular intervention (Stent/ PTA)
  2. surgical bypass
  3. to select the sites of surgical anastomosis
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13
Q

What is considered Abdominal vascular disease?

A
  • aortic aneurysm
  • mesenteric artery disease
  • renal artery disease
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14
Q

Atherosclerotic etiology
* increased prevalence in pts with CAD, CVD, PAD
* Risk factors essentially the same for each

Fibromuscular dysplasia (FMD)
* accounts for 40% of cases
* also seen in the carotid arteries
* congenital arterial abnormality of fibrous, muscular and elastic components

A

Renal Artery Stenosis

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15
Q

caused by renal artery stenosis (kidney senses low blood flow because of the blockage)
* secondary to atherosclerosis- usually origin and proximal segment of renal artery
* fibromuscular dysplasia- usually mid to distal segment of renal artery or carotid artery
* occlusion

A

Renovascular hypertension

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16
Q

Where is the most common place for aortic aneurysms to occur?

A

infra-renal aorta

17
Q

how would patients with an abdominal aortic aneurysm present?

A
  1. most patients are asymptomatic
  2. symptomatic (unruptured)- presents with abdominal, flank or back pain. On examination, abdominal bruits may be heard and a pulsitile abdominal mass may be palpated
  3. symptomatic (ruptured)- hypotension or syncope, flank ecchymosis
18
Q

how should AAA be diagnosed?

A
  1. CT scan with IV contrast- best initial test in symptomatic, hemodynamically stable patients
  2. ultrasound- initial study of choice in hemodynamically unstable patients
  3. Asymptomatic with suspected AAA- abdominal ultrasound is is the initial test

MRA can also be used

19
Q
  • sudden brain damage; lack of blood flow to the brain caused by a clot or rupture of a blood vessel
  • ischemic = clot
  • hemorrhagic = bleed
  • dx= carotid bruit
  • suspicion leads to ultrasound of carotid arteries
  • any abnormality on ultrasound: confirm with MRA or CT
A

Stroke

20
Q

What are the major goals of treating PAD?

A

Limb outcomes
* Improved ability to walk (increase in peak walking distance, improvement in quality of live
* prevention of progression to CLI and amputation

Cardiovascular morbidity and mortality outcomes
* decrease in morbidity from non-fatal MI and stroke
* decrease in cardiovascular mortality from fatal MI and stroke

getting the pt walking will help grow new collateral arteries

21
Q

ways to treat the underlying causes of PAD?

A
  • Smoking cessation (laser, licorice, medications, hypnotism)
  • antiplatelet therapy
  • hyperlipidemia (lifestyle and/or medications
  • hypertension (pts should receive hypertension tx)
  • keep diabetes under good control
  • get active, lose weight
22
Q

indications lower extremities:
* persistent limiting claudication, preventing working and/or ADL
* rest pain
* tissue loss/non healing ulcers (get pt walking!!)

abdominal aorta or renal arteries
carotid arteries

A

Treatment with Angioplasty/Stent

23
Q

Lower extremity arterial disease
* bypass (eg. femoral to popliteal artery)
* vein or synthetic graft used (synthetic if patient does not have viable veins or if they are too small)

Abdominal aorta
* use criteria set, when the risk of rupture outweighs the risk of this procedure

carotid endarterectomy

A

Treatment with Surgery

24
Q

what are microcirculatory diseases?

A

raynaud phenomenon
buerger’s disease

25
Q

repetitive episodes of
* biphasic colour change (at lease 2 of pallor, cyanosis, erythema)
* in either cold or normal environment

primarily affects fingers, can affect toes, thumbs, nipples, nose, earlobes
episodes accompanied by pain +/- numbness
pulses present
necrosis/tissue damage suggestive of secondary cause

A

Raynauds

26
Q

what is the pathogenesis and causes of raynauds?

A

pathogenesis
* increased vasoconstriction, decreased vasodilation, reduced blood flow/procoagulant tendency, endothelial damage

Causes
* primary (10-15% of healthy population, female predominance)
* secondary (drugs eg beta blockers, connective tissue disorders, eating disorders, haematological, vascular occlusion, occupation e.g vibrating tool use, hypothyroidism, carpal tunnel syndrome

27
Q

treatment of raynauds

A

indentify and treat underlying etiology
* maintenance of core temp, avoidance of cold exposure, cessation of vasoconstrictive rx e.g beta blockers, gloves (heated), smoking cessation

Promote vasodilation
* calcium channel blockers, dyhropyridine (nifedipine better than amlodipine), nitrates, prostaglandins, phosphodiester V inhibitors

Prevent vasoconstriction
* ACEi/ARB, alpha blockers, SSRIs, endothelial receptor antagonists

28
Q
  • Thromobangiitis obliterans
  • combination of acute inflammation and thrombosis of arteries and veins
  • upper and lower extremities affected
  • obstructs bloodflow to tissues; pain, damage
  • can lead to skin ulcerations and gangrene
  • advanced stages- can affect other parts of the body
A

Buerger’s disease

29
Q

symptoms of buerger’s disease?

A
  • pain or tenderness
  • numbness and tingling in the hands/feet
  • skin ulcers or gangrene of the fingers/toes
  • discoloration
  • two or more limbs affected
  • pain may increase with activity such as walking and decrease with rest
  • pulse may be decreased/absent in the affected extremity
  • symptoms may worsen with exposure to cold or with emotional stress
30
Q

causes and diagnosis of buerger’s disease?

A

Causes
* associated with moderate-heavy tobacco use
* seen in both cigarette and tobacco chewing
* thought to be autoimmune reaction triggered by tobacco

Diagnosis
* suspicion- start evaluation of vascular/rheumatological diseases early
* doppler ultrasound
* angiogram of upper/lower extremities
* skin biopsies rarely used

Cardiology (8 decks)

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