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
2
Q
what commonly causes PAD?
A
atherosclerosis in patients over 40
3
Q
where does PAD most commonly occur?
A
lower extremities
4
Q
patients with PAD have an increased risk of …… and ……. events
A
cardio and cerebrovascular.
5
Q
where at in the artery are lesions common?
A
at the branch points
6
Q
Primary sites of involvement for PAD
A
- abdominal aorta and iliac arteries
- popliteal and femoral arteries
- tibial and peroneal arteries
7
Q
why are lesions more common at the arterial branch points?
A
- increased turbulence
- altered shear stress
- intimal injury
8
Q
risk factors for PAD
A
- smoking*
- DM*
- hypercholesterolemia
- hypertension
- renal insufficiency
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
10
Q
distal aorta and proximal common iliac disease is mc in …
A
white, male smokers aged 50-60
11
Q
femoral-popliteal disease is MC in …
A
- patients over 60
- black and hispanics
12
Q
tibial artery disease is MC in …
A
diabetic and elderly patients
13
Q
most typical symptom of PAD
A
intermittent claudication
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
14
Q
how long does it take for symptoms to subside after exercise cessation?
A
10 min
15
Q
pseudoclaudication
A
painful cramps that are not caused by peripheral artery disease, but can mimic PAD
16
Q
common causes of pseudoclaudication
A
- spinal canal stenosis
- herniated disc impingement on sciatic nerve
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
18
Q
patients with ….. and ….. artery disease typically do not have claudication
A
tibial; pedal
19
Q
……. may be the first sign of vascular insufficiency
A
rest pain or ulceration.
20
Q
how is PAD rest pain relieved?
A
dependency (hanging foot off the edge of the bed)
21
Q
PAD classification aims to grade …… and ……. responsible for symptoms
A
symptoms and anatomic lesions
22
Q
MC tool to assess anatomic lesion classification
A
Trans-Atlantic Inter-Society Consensus (TASCII)
23
Q
tool used to classify clinical severity of PAD
A
wound, ischemia, and foot infection classification (WIFI)
24
most important PE for PAD
pulse exam
25
classic PE findings for PAD
* decreased or absent pulses peripheral to obstruction
* cool skin
* cyanotic
* atrophy of muscles
* hair loss
* ulcers
26
Leg lift test
-elevate leg to 60 degrees for 1 minute
-positive test if pallow occurs
27
assess for dependent rubor
-evaluate when patient become seated after being supine
-foot will become extremely red
28
best screening tool for PAD
ankle brachial index
29
t/f the majority of the time, ABI, history, and PE can allow you to make a PAD diagnosis with no other testing
true
30
who should be screened for PAD?
* patients with history or PE findings suggestive of PAD
* patient with increased risk of PAD but without H&P findings
31
interpretation of ABI
* >1.40: non-compressible vessel
* 1.4-1: normal
* .99-.91: borderline
* .90-.70: diagnostic of PAD
* .69-.40: moderate
* <.40: severe
32
limitations of ABI
* incompressible arteries
* not good for detecting mild disease
* not designed to define degree of functional limitation
* does not define location of disease
33
.... is used when the ABI os over 1.4
toe brachial index (TBI)
34
.... are typically spared from medial arterial disease
digital vessels
35
TBI< ..... is abnormal and diagnostic of PAD
0.70
36
treadmill exercise test assesses ......
functional capacity
37
treadmill exercise test cannot be used if...
* patient has non-compressible vessels
* cannot walk on treadmill
38
procedure of treadmill exercise test
* 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
39
a decrease in ABI of more than .... immediately following exercise if diagnostic of PAD
20 %
40
segmental limb pressure
multiple cuffs placed on legs to obtain a more specific information
41
a decrease between two consecutive levels of ..... suggests arterial disease of the artery proximal to the cuff
>30mmHg
42
uses of arterial duplex
* determining severity of disease
* confirming PE findings
* useful if intervention is being considered to assess risk/benefit ratio
43
when should MRA be condisered?
when surgical intervention is considered
44
magnetic resonance angiography (MRA)
procedure used to examine blood vessels
45
when should CTA be considered?
when surgical intervention is considered
46
gold standard for peripheral vascular imaging
digital subtraction angiography
47
goals of PAD therapy
* relieve symptoms
* lower risk of cardio progression and complications
48
risk factor modification for PAD
* antiplatelet therapy
* smoking cessation
* lipid lowering therapy
* glycemic control
* blood pressure control
* diet and exercise
* obesity
49
antiplatelet therapy for PAD
ASA or Plavix alone
50
......may reduce cardiovascular events in patients with PAD
ace inhibitors
51
MOA of cilost
inhibit phosphodiesterase activity and suppress degradation of cAMP resulting in an increase in cAMP in platelets and blood vessels
52
cilostazol has ..... and .... properties
vasodilator and antiplatelet
53
CI of cilostazol
-HF
54
SE of cilostazol
* edema
* HA
* GI upset
* palpitations
* bleeding
55
counseling point for cilostazol
do not take with food because it is protein bound
56
exercise for PAD patients
3-5 sessions of 35-50 minutes per week
57
surgical bypass
bypass grafts with prosthetic material or native veins
58
indications for surgical bypass
continues intermittent claudication symptoms dispite other therapies
59
endovascular therapy
* angioplasty
* stenting
* atherectomy
60
indications for endovascular therapy
continues intermittent claudication symptoms despite other therapies
61
loss of touch sensation requires revascularization within .... to save the limb
3 hours
62
thrombus occurs when...
stable atheroma with fibrous cap suffers plaque rupture leading to thrombus development and acute occlusion
63
patient with thrombus typically has history of ......
intermittent claudication
64
why may presentation of thrombus not be as dramatic if there is prior history of PAD?
angiogenesis leading to development of collateral flow
65
MC cause of emboli
afib
66
MC cause of thrombi
atherosclerosis
67
6 Ps of acute occlusion
* pallor
* pain
* pulseless
* paralysis
* poikilothermia
* parathesias
68
which symptoms (6Ps) develop in the first hour?
* pain
* paresthesia
* poikilothermia
69
diagnosis of acute occlusion
clinical diagnosis
70
doppler of acute occlusion
demonstrates little to no flow in distal vessels
71
when should acute imaging be avoided in acute occlusion?
if light touch is compromised (it will only cause a delay in therapy)
72
management of acute occlusion
immediate revascularization
73
Revascularization of acute occlusion should be accomplished within ......
3 hours
74
as soon as the diagnosis of acute occlusion is made.....
IV bolus of heparin and continuous infusion should be given
75
one the patient is stable, ..... must be determined
the source of the occlusion
76
if the occlusion is due to a PAD thrombus, how is it managed?
like any other PAD patient
77
if the occlusion is due to an embolus, how is it managed?
most require warfarin for at least 3 months or longer
78
when is it considered a AAA?
over 3cm
79
where do 90% of AAAs occur?
below the renal arteries
80
risk factors of AAA
* male
* smoker
* family history
* age
81
fusiform AAA
Circumferential expansion of the aorta
82
saccular AAA
Outpouching of a segment of the aorta
83
symptoms of AAA rupture
* severe pain
* palpable abdominal mass
* hypotension
83
diagnosis of AAA
abdominal ultrasound
83
presentation of AAA
* most are asymptomatic
* Pain over mid abdomen
* radiates to lower back
84
when is an abdominal CT performed for AAA?
when aneurysms near the diameter threshold for treatment (5.5 cm)
85
why would a CT be done for AAA?
gives a more reliable assessment of aneurysm diameter
86
what type of CT is done for AAA?
CT with contrast
87
once an aneurysm is identified, routine follow up with ____ will determine rate of growth
US
88
screening for AAA
* all men 65-75 who have ever smoked
* men 65-75 with family history
89
when should AAAs be referred to vascular surgery?
4.5cm
90
which type of repair for AAA has better results?
open repair
91
MC cause of thoracic aortic aneurysm
atherosclerosis
92
presentation of thoracic aneurysm
* most are asymptomatic
* substernal back or neck pain
* pressure on esophagus or trachea
* hoarseness
93
Xray of thoracic aneurysm
mediastinal widening
94
imaging of choice for thoracic aneurysm
CT with contrast
95
management of thoracic aneurysm
surgical repair if 5.5cm or greater
96
aortic dissection
spontaneous intimal tear develops and blood dissects into the media of the aorta
97
type A dissection
involves the arch proximal to the left subclavian artery
98
involves the arch proximal to the left subclavian artery
occurs in the proximal descending thoracic aorta typically just beyond the left subclavian
99
risk factors for aortic dissection
* atherosclerosis
* aging
* pregnancy
* HTN
100
presentation of aortic dissection
* severe, persistent chest pain
* radiated to back and neck
* hypertensive
* ischemia
* diastolic murmur
101
signs of disrupted perfusion with aortic dissection
* syncope
* paralysis of lower extremities
* intestinal ischemia
* renal insufficiency
* diminished peripheral pulses
102
why may you hear a diastolic murmur in aortic dissection?
dissection close to aortic valve, causing regurg
103
diagnosis of aortic dissection
CT of chest and abdomen with contrast
104
EKG of aortic dissection
LVH
105
management of aortic dissection
* BP control with beta blockers until they can get surgery
* morphine for pain
* surgery
106
goal BP for aortic dissection
lower systolic to 100-120
107
urgent surgical intervention is required for all ......
type A dissections
108
...... with ...... require urgent surgery as well
type b dissections; signs of malperfusion of target tissues
109
etiology of buergers disease
segmental, inflammatory, thrombotic processes that occur in the small distal arteries and occasionally veins of extremities
110
presentation of buergers disease
* starts with toes/feet
* digital ischemic rest pain
* ischemic ulcerations on the toes, feet, or fingers
111
buergers disease is closely linked to....
heavy tobacco use
112
MC vessels involves with buergers disease
plantar and digital vessels of foot/leg
113
diagnosis of buergers disease
* arterial duplex
* CTA or MRA
* most testing is done to rule out other causes
114
management of buergers disease
* absolute tobacco cessation
* amputation of ischemic areas
* NSAIDS or opioids for pain control
115
complications of buergers disease
* ulcerations
* gangrene
* infection
