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