Peripheral Arterial Disease

Question 1

`What is the MC form of PAD?

Answer 1

Atherosclerosis

Question 2

A 45 yo Asian male smoker presents with claudication of his forearm, migratory superficial vein thrombophlebitis, and a problem with his fingers. He says that when they get cold they turn white for a bit and then they turn red and throb, eventually resolving. What is the likely diagnosis? What is the pathological cause?

Answer 2

Thromboangiitis Obliterans (Buerger’s Dz)
Inflammatory occlusion of sm/med vessels
Idiopathic

Question 3

A 62 yo male smoker presents with calf claudication during exercise that resolves with rest. You can feel his popliteal pulse, but his fibular pulse and pedal pulse are both diminished. What disease do you suspect? What test would you do to confirm your diagnosis?

Answer 3

Atherosclerosis

Confirm w/ ABI (ABI > 1 = normal, ABI

Question 4

A female smoker presents with HTN and claudication. You order an angiograph which shows a “string of beads” appearance. What disease is most likely?

Answer 4

Fibromuscular Dysplasia

Similar to PAD but non-atherosclerotic

Question 5

A pt presents with bilateral butt claudication. His femoral pulse is absent and you hear an aortic bruit. ABI shows LE blunting. What is the diagnosis? How will you treat this pt?

Answer 5

Aortoiliac Artery Disease
Endovascular surgery
Bypass grafting
Refer if progressive, short-distance claudication

Question 6

A 58 yo female presents with pain in her lower thigh. The pain is worse when she walks and is relieved when she sits down. She has a diminished tibial pulse and you could not find her popliteal pulse. You notice smooth, shiny skin on her lower legs and they are cool to the touch. What test should you run to confirm your diagnosis? What treatment do you recommend?

Answer 6

Atherosclerosis
ABI to confirm severe AS
Smoking cessation, risk factor reduction (smoking, DM, high cholesterol, HTN), platelet inhibitors, exercise 30 min/d, AVOID compression socks

Question 7

What are the 3 main goals when treating PAD?

Answer 7

Improve walking ability
Prevent ischemia/amputation
Reduce M&M from MI/stroke

Question 8

A 64 yo male diabetic smoker presents with leg pain. You notice hair loss, smooth, shiny skin, and pallor of his lower legs, and on exam you hear a femoral bruit. What disease does this pt most likely have? What is the underlying pathology?

Answer 8

Severe Atherosclerosis
Most likely due to hardening of the arterial branch sites (abdominal aorta/iliac, femoral/popliteal (MC), or distal vessels)

Question 9

A diabetic patient presents with foot claudication and ischemia. She complains of severe, burning pain in her foot even at rest, and says that when she elevates her foot it becomes inflamed and red. You decide to do an ABI. What diagnostic result would you expect to see? How would you treat her?

Answer 9

Lower Leg/Foot Artery Disease

ABI

Question 10

A 59 yo male smoker presents w/ claudication in his calves, Raynaud’s phenomenon, and migratory superficial vein thrombophlebitis. What disease does he have? What treatment do you recommend?

Answer 10

Thromboangiitis Obliterans (Buerger's Dz)
Non-specific treatment
Smoking cessation
Arterial bypass
Local debridement/amputation

Question 11

A pt presents with left calf claudication. The same leg is atrophic. She has a normal femoral pulse but decreased popliteal and pedal pulses. What is the most likely diagnosis? What treatment do you recommend?

Answer 11

Popliteal Artery Disease
Angioplasty w/ or w/o stenting
Bypass grafting
Refer if progressive, short-distance claudication

Question 12

A 44 yo female with a 30 pack year Hx of smoking presents with claudication (relieved w/ rest), a renal bruit, and decreased femoral pulses. Angiograph shows what looks like a string of beads in her renal arteries. What is the most likely diagnosis? How will you treat this pt?

Answer 12

Fibromuscular Dysplasia
Conservative Tx (same as PAD: smoking cessation, risk factor reduction, platelet inhibitors, exercise, foot care)
Stent placement

Question 13

A 24 yo female presents with malaise, fever, nigh sweats, arthralgia, and weight loss. You note absent pulses, BP is 155/100, and labs show elevated ESR, anemia, and elevated immunoglobulin. What disease do you suspect? What treatment do you recommend?

Answer 13

Takayasu’s Arteritis
Glucocorticoid therapy
Surgery

Question 14

A 62 yo female presents with fever, fatigue, anorexia, weight loss, sweats, arthralgia, scalp pain, tongue claudication, and jaw pain. Labs show anemia and elevated ESR. What do you suspect? How do you confirm your diagnosis?

Answer 14

Giant Cell Arteritis

Temporal artery biopsy

Question 15

A pt presents with sudden onset pain, pallor, pulselessness, parasthesia, poikilothermia, and paralysis of her left forearm. What disease do you suspect? What is the pathological cause of this Dz?

Answer 15

Acute Arterial Occlusion of a Limb
Sudden loss of blood flow to the extremity
Embolism
Primary thrombosis

Question 16

A pt presents with pain, numbness, weakness, and swelling of his fingers. The tip of his pinky finger appears black. Wright’s maneuver and Adson’s test are positive, so you order a CXR which shows a cervical rib. What is your diagnosis? How would you treat this pt?

Answer 16

Thoracic Outlet Syndrome

Surgery b/c of gangrene

Question 17

A pt presents with fever, fatigue, anorexia, sweats, arthralgia, jaw and tongue pain, and ischemic optic neuropathy. Biopsy shows giant cell arteritis. What treatment do you recommend?

Answer 17

Glucocorticoid treatment

Prednisone

Question 18

A pt presents with lower leg claudication. His toes have a bluish tinge but you don’t feel any popliteal masses. What diagnostic test should you run? What treatment do you recommend?

Answer 18

Peripheral Artery Aneurysm
Doppler U/S (gold standard)
Amputation (1/3)
Repair if < 2 cm, mural thrombus, or symptomatic

Question 19

A patient presents with sudden pain, loss of sensation, and loss of movement in her right lower leg. On exam you note that it is white, cool, and the tibial pulse is absent. Doppler U/S shows little blood flow to her lower leg. What treatment do you recommend?

Answer 19

Acute Arterial Occlusion of a Limb

Immediate revascularization + Heparin IV

Question 20

A pt presnts with numbness, weakness, and swelling of his right hand. He mentions that he first noticed the symptoms while he was pitching for his company’s baseball team. What disease do you suspect? What treatment do you recommend?

Answer 20

Thoracic Outlet Syndrome
Conservative Tx:
PT
Avoid aggravating factors

Question 21

A pt comes in with white hands with a blue tinge around the finger nails. A few minutes later his hands turn red and start to throb. He is worried because although this has been happening for a while, it has slowly been progressing to involve more of his hands. What disease is likely? What treatment do you recommend?

Answer 21

Raynaud’s Phenomenon
Stay warm and protect hands from injury
Smoking cessation
CCB’s

Question 22

A 23 yo female presents with persistent cyanosis of both hands. She has moist palms and the cyanosis is non-blanchable and worse in the cold. She denies any pain and exam shows normal pulses. What disease is most likely? How will you treat her?

Answer 22

Acrocyanosis
Reassurance
Dress warmly and avoid cold

Question 23

A pt presents with an ulcer on his lower left leg. The skin has a mottled, nest-like appearance and you note a red-blue discoloration around the ulcer. What is the diagnosis? How will you treat it?

Answer 23

Livedo Reticularis
Primary: avoid the cold
Secondary: treat underlying Dz

Question 24

A 29 yo female presents with raised erythematous lesions on her lower right leg. She complains of itching, burning, and pain and on inspection you notice blisters. What is the likely diagnosis? What treatment should you recommend?

Answer 24

Pernio (Chilbains)
Self-limiting
Can recur
Avoid cold exposure
Wound care

Question 25

A pt presents because he is worried about his forearms and lower legs, which look funny. They have a red-blue tint and a mottled, nest-like appearance, but he doesn’t report any symptoms? What disease is this most likely to be? How will you treat him?

Answer 25

Primary Livedo Reticularis

Avoid the cold