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Internal Med EOR > Peripheral Arterial Disease > Flashcards

Peripheral Arterial Disease Flashcards

1
Q

peripheral arterial disease (PAD)

A

presence of a stenosis or occlusion n the aorta or arteries of the limbs

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2
Q

what commonly causes PAD?

A

atherosclerosis in patients over 40

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3
Q

where does PAD most commonly occur?

A

lower extremities

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4
Q

patients with PAD have an increased risk of …… and ……. events

A

cardio and cerebrovascular.

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5
Q

where at in the artery are lesions common?

A

at the branch points

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6
Q

Primary sites of involvement for PAD

A
  • abdominal aorta and iliac arteries
  • popliteal and femoral arteries
  • tibial and peroneal arteries
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7
Q

why are lesions more common at the arterial branch points?

A
  • increased turbulence
  • altered shear stress
  • intimal injury
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8
Q

risk factors for PAD

A
  • smoking*
  • DM*
  • hypercholesterolemia
  • hypertension
  • renal insufficiency
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9
Q

ACC/AHA recommends patients in the following categories be evaluated for PAD

A
  • over 70 yo
  • 50-69 with history of smoking or DM
  • 40-49 with DM and at least one other risk factor
  • known atherosclerosis at other sites
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10
Q

distal aorta and proximal common iliac disease is mc in …

A

white, male smokers aged 50-60

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11
Q

femoral-popliteal disease is MC in …

A
  • patients over 60
  • black and hispanics
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12
Q

tibial artery disease is MC in …

A

diabetic and elderly patients

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13
Q

most typical symptom of PAD

A

intermittent claudication

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13
Q

characteristics of claudication in PAD

A

characterized by pain, aching, cramping, numbness, or muscle fatigue that occurs during exercise and is relieved by rest

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14
Q

how long does it take for symptoms to subside after exercise cessation?

A

10 min

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15
Q

pseudoclaudication

A

painful cramps that are not caused by peripheral artery disease, but can mimic PAD

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16
Q

common causes of pseudoclaudication

A
  • spinal canal stenosis
  • herniated disc impingement on sciatic nerve
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17
Q

differences between claudication and pseudoclaudication

A
  • claudication: not associated with standing, lasts shorter amount of time, exercise induced
  • pseudoclaudication: occurs with standing, can last up to 30 minutes, not necessarily exercise induced
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18
Q

patients with ….. and ….. artery disease typically do not have claudication

A

tibial; pedal

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19
Q

……. may be the first sign of vascular insufficiency

A

rest pain or ulceration.

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20
Q

how is PAD rest pain relieved?

A

dependency (hanging foot off the edge of the bed)

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21
Q

PAD classification aims to grade …… and ……. responsible for symptoms

A

symptoms and anatomic lesions

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22
Q

MC tool to assess anatomic lesion classification

A

Trans-Atlantic Inter-Society Consensus (TASCII)

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23
Q

tool used to classify clinical severity of PAD

A

wound, ischemia, and foot infection classification (WIFI)

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24
Q

most important PE for PAD

A

pulse exam

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25
Q

classic PE findings for PE

A
  • decreased or absent pulses peripheral to obstruction
  • cool skin
  • cyanotic
  • atrophy of muscles
  • hair loss
  • ulcers
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26
Q

Leg lift test

A

-elevate leg to 60 degrees for 1 minute
-positive test if pallow occurs

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27
Q

assess for dependent rubor

A

-evaluate when patient become seated after being supine
-foot will become extremely red

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28
Q

best screening tool for PAD

A

ankle brachial index

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29
Q

t/f the majority of the time, ABI, history, and PE can allow you to make a PAD diagnosis with no other testing

A

true

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30
Q

who should be screened for PAD?

A
  • patients with history or PE findings suggestive of PAD
  • patient with increased risk of PAD but without H&P findings
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31
Q

interpretation of ABI

A
  • > 1.40: non-compressible vessel
  • 1.4-1: normal
  • .99-.91: borderline
  • .90-.70: diagnostic of PAD
  • .69-.40: moderate
  • <.40: severe
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32
Q

limitations of ABI

A
  • incompressible arteries
  • not good for detecting mild disease
  • not designed to define degree of functional limitation
  • does not define location of disease
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33
Q

…. is used when the ABI os over 1.4

A

toe brachial index (TBI)

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34
Q

…. are typically spared from medial arterial disease

A

digital vessels

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35
Q

TBI< ….. is abnormal and diagnostic of PAD

A

0.70

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36
Q

treadmill exercise test assesses ……

A

functional capacity

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37
Q

treadmill exercise test cannot be used if…

A
  • patient has non-compressible vessels
  • cannot walk on treadmill
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38
Q

procedure of treadmill exercise test

A
  • resting ABI measured at baseline
  • then patient walks on treadmill until they cannot tolerate claudication
  • patient resumes supine position and ABI measurements are taken every 1-2 minutes until they reach pre-exercise level
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39
Q

a decrease in ABI of more than …. immediately following exercise if diagnostic of PAD

A

20 %

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40
Q

segmental limb pressure

A

multiple cuffs placed on legs to obtain a more specific information

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41
Q

a decrease between two consecutive levels of ….. suggests arterial disease of the artery proximal to the cuff

A

> 30mmHg

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42
Q

uses of arterial duplex

A
  • determining severity of disease
  • confirming PE findings
  • useful if intervention is being considered to assess risk/benefit ratio
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43
Q

when should MRA be condisered?

A

when surgical intervention is considered

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44
Q

magnetic resonance angiography (MRA)

A

procedure used to examine blood vessels

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45
Q

when should CTA be considered?

A

when surgical intervention is considered

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46
Q

gold standard for peripheral vascular imaging

A

digital subtraction angiography

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47
Q

goals of PAD therapy

A
  • relieve symptoms
  • lower risk of cardio progression and complications
48
Q

risk factor modification for PAD

A
  • antiplatelet therapy
  • smoking cessation
  • lipid lowering therapy
  • glycemic control
  • blood pressure control
  • diet and exercise
  • obesity
49
Q

antiplatelet therapy for PAD

A

ASA or Plavix alone

50
Q

……may reduce cardiovascular events in patients with PAD

A

ace inhibitors

51
Q

MOA of cilost

A

inhibit phosphodiesterase activity and suppress degradation of cAMP resulting in an increase in cAMP in platelets and blood vessels

52
Q

cilostazol has ….. and …. properties

A

vasodilator and antiplatelet

53
Q

CI of cilostazol

A

-HF

54
Q

SE of cilostazol

A
  • edema
  • HA
  • GI upset
  • palpitations
  • bleeding
55
Q

counseling point for cilostazol

A

do not take with food because it is protein bound

56
Q

exercise for PAD patients

A

3-5 sessions of 35-50 minutes per week

57
Q

surgical bypass

A

bypass grafts with prosthetic material or native veins

58
Q

indications for surgical bypass

A

continues intermittent claudication symptoms dispite other therapies

59
Q

endovascular therapy

A
  • angioplasty
  • stenting
  • atherectomy
60
Q

indications for endovascular therapy

A

continues intermittent claudication symptoms despite other therapies

61
Q

loss of touch sensation requires revascularization within …. to save the limb

A

3 hours

62
Q

thrombus occurs when…

A

stable atheroma with fibrous cap suffers plaque rupture leading to thrombus development and acute occlusion

63
Q

patient with thrombus typically has history of ……

A

intermittent claudication

64
Q

why may presentation of thrombus not be as dramatic if there is prior history of PAD?

A

angiogenesis leading to development of collateral flow

65
Q

MC cause of emboli

A

afib

66
Q

MC cause of thrombi

A

atherosclerosis

67
Q

6 Ps of acute occlusion

A
  • pallor
  • pain
  • pulseless
  • paralysis
  • poikilothermia
  • parathesias
68
Q

which symptoms (6Ps) develop in the first hour?

A
  • pain
  • paresthesia
  • poikilothermia
69
Q

diagnosis of acute occlusion

A

clinical diagnosis

70
Q

doppler of acute occlusion

A

demonstrates little to no flow in distal vessels

71
Q

when should acute imaging be avoided in acute occlusion?

A

if light touch is compromised (it will only cause a delay in therapy)

72
Q

management of acute occlusion

A

immediate revascularization

73
Q

Revascularization of acute occlusion should be accomplished within ……

A

3 hours

74
Q

as soon as the diagnosis of acute occlusion is made…..

A

IV bolus of heparin and continuous infusion should be given

75
Q

one the patient is stable, ….. must be determined

A

the source of the occlusion

76
Q

if the occlusion is due to a PAD thrombus, how is it managed?

A

like any other PAD patient

77
Q

if the occlusion is due to an embolus, how is it managed?

A

most require warfarin for at least 3 months or longer

78
Q

when is it considered a AAA?

A

over 3cm

79
Q

where do 90% of AAAs occur?

A

below the renal arteries

80
Q

risk factors of AAA

A
  • male
  • smoker
  • family history
  • age
81
Q

fusiform AAA

A

Circumferential expansion of the aorta

82
Q

saccular AAA

A

Outpouching of a segment of the aorta

83
Q

symptoms of AAA rupture

A
  • severe pain
  • palpable abdominal mass
  • hypotension
83
Q

diagnosis of AAA

A

abdominal ultrasound

83
Q

presentation of AAA

A
  • most are asymptomatic
  • Pain over mid abdomen
  • radiates to lower back
84
Q

when is an abdominal CT performed for AAA?

A

when aneurysms near the diameter threshold for treatment (5.5 cm)

85
Q

why would a CT be done for AAA?

A

gives a more reliable assessment of aneurysm diameter

86
Q

what type of CT is done for AAA?

A

CT with contrast

87
Q

once an aneurysm is identified, routine follow up with ____ will determine rate of growth

A

US

88
Q

screening for AAA

A
  • all men 65-75 who have ever smoked
  • men 65-75 with family history
89
Q

when should AAAs be referred to vascular surgery?

A

4.5cm

90
Q

which type of repair for AAA has better results?

A

open repair

91
Q

MC cause of thoracic aortic aneurysm

A

atherosclerosis

92
Q

presentation of thoracic aneurysm

A
  • most are asymptomatic
  • substernal back or neck pain
  • pressure on esophagus or trachea
  • hoarseness
93
Q

Xray of thoracic aneurysm

A

mediastinal widening

94
Q

imaging of choice for thoracic aneurysm

A

CT with contrast

95
Q

management of thoracic aneurysm

A

surgical repair if 5.5cm or greater

96
Q

aortic dissection

A

spontaneous intimal tear develops and blood dissects into the media of the aorta

97
Q

type A dissection

A

involves the arch proximal to the left subclavian artery

98
Q

involves the arch proximal to the left subclavian artery

A

occurs in the proximal descending thoracic aorta typically just beyond the left subclavian

99
Q

risk factors for aortic dissection

A
  • atherosclerosis
  • aging
  • pregnancy
  • HTN
100
Q

presentation of aortic dissection

A
  • severe, persistent chest pain
  • radiated to back and neck
  • hypertensive
  • ischemia
  • diastolic murmur
101
Q

signs of disrupted perfusion with aortic dissection

A
  • syncope
  • paralysis of lower extremities
  • intestinal ischemia
  • renal insufficiency
  • diminished peripheral pulses
102
Q

why may you hear a diastolic murmur in aortic dissection?

A

dissection close to aortic valve, causing regurg

103
Q

diagnosis of aortic dissection

A

CT of chest and abdomen with contrast

104
Q

EKG of aortic dissection

A

LVH

105
Q

management of aortic dissection

A
  • BP control with beta blockers until they can get surgery
  • morphine for pain
  • surgery
106
Q

goal BP for aortic dissection

A

lower systolic to 100-120

107
Q

urgent surgical intervention is required for all ……

A

type A dissections

108
Q

…… with …… require urgent surgery as well

A

type b dissections; signs of malperfusion of target tissues

109
Q

etiology of buergers disease

A

segmental, inflammatory, thrombotic processes that occur in the small distal arteries and occasionally veins of extremities

110
Q

presentation of buergers disease

A
  • starts with toes/feet
  • digital ischemic rest pain
  • ischemic ulcerations on the toes, feet, or fingers
111
Q

buergers disease is closely linked to….

A

heavy tobacco use

112
Q

MC vessels involves with buergers disease

A

plantar and digital vessels of foot/leg

113
Q

diagnosis of buergers disease

A
  • arterial duplex
  • CTA or MRA
  • most testing is done to rule out other causes
114
Q

management of buergers disease

A
  • absolute tobacco cessation
  • amputation of ischemic areas
  • NSAIDS or opioids for pain control
115
Q

complications of buergers disease

A
  • ulcerations
  • gangrene
  • infection

Internal Med EOR (16 decks)

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