Peripheral Artery Disease Flashcards
What is the underlying pathology for peripheral artery disease (PAD)?
Atherosclerosis of peripheral arteries, most commonly affecting the lower extremities.
What is the most commonly affected site in PAD?
Lower extremities, particularly the femoral and popliteal arteries.
What are the major risk factors for PAD?
- Smoking
- Diabetes mellitus
- Hypertension
- Hyperlipidemia
- Chronic kidney disease
- History of coronary artery disease
What is the number one risk factor for PAD?
Smoking.
What is the most common initial symptom of PAD?
Intermittent claudication, which is induced by walking and relieved with rest. Depending on the severity of disease, patients can have pain with exertion (claudication), rest pain, tissue ulceration, or gangrene.
What should be on the differential diagnosis list with “claudication?”
- Atherosclerosis
- Neurogenic
- Venous thrombosis
What muscle groups are most commonly affected by claudication in PAD?
Calves, quadriceps, and gluteal muscles.
What are signs of severe PAD?
- Pain rest
- Dependent rubor (redness)
- Hairless legs
- Shiny skin
- Muscle atrophy
- Ulcerations
Peripheral artery disease (PAD) causes ischemic ulcers that most commonly develop at … ?
toes, heels, and lateral malleolus.
What is Buerger’s sign?
Elevation of the leg causes pallor, and dangling the leg causes bright red coloration due to reactive hyperemia.
What is the ADSON or scalene maneuver?
Radial pulse diminishes or disappears with turning chin to same side due to a decrease in space between scaleneus anterior and medius.
What is Rutherford’s classification for PAD?
A scale from 0-6, with 0 being asymptomatic and 6 being major tissue loss.
What are the symptoms associated with Leriche syndrome?
Aortic iliac obstruction leading to bilateral thigh and gluteal claudication, erectile dysfunction, and absent femoral pulses.
Which vasculitis is strongly associated with PAD?
Takayasu arteritis, which affects large vessels and can cause ischemic symptoms in the extremities.
What is the first diagnostic test for PAD?
Ankle-brachial index (ABI).
What ABI value is considered abnormal?
ABI <0.9 is diagnostic of PAD.
What ABI value indicates severe PAD?
ABI <0.4, which suggests severe ischemia requiring intervention.
What is the next step if ABI is equivocal?
Exercise ABI testing to assess functional limitations.
What imaging tests can be used for further evaluation of PAD?
Doppler ultrasound, CT angiography, MR angiography, or conventional angiography.
What is the first-line management for PAD?
1) Lifestyle modifications including smoking cessation
2) Risk factor control (anti-PLT meds, statins, antihypertensives, diabetes control).
3) Exercise therapy
4) Adjunctive medications
5) Revascularization intervention
What medications are given for primary or secondary prevention in patients with PAD?
Statins
- For diagnosed PAD, patients should be provided statins regardless of their lipid levels.
- Patients age ≤75 should be initiated on high-intensity statin therapy (eg, atorvastatin 40-80 mg daily, rosuvastatin 20-40 mg daily), regardless of baseline cholesterol levels; this lowers the risk of cardiovascular events and may in some cases improve claudication symptoms.
What antiplatelet medications are recommended for PAD?
Aspirin or clopidogrel.
PAD is a representation of atherosclerotic cardiovascular disease (ASCVD) and denotes an increased risk of future cardiovascular events (eg, myocardial infarction, stroke). The initiation of aspirin has demonstrated decreased incidence of stroke in patients with PAD and is recommended at the time of diagnosis.
How are patients walked for PAD?
Patients should participate in 30-45 minutes of supervised walking ≥3 times a week for >3 months. Once the walking time required to develop claudication is determined, the sessions are gradually increased until the patient can walk for a longer period without developing symptoms. Patients may experience moderate increases in symptom-free walking distance. In addition to cardiovascular risk factor management (eg, smoking cessation), a supervised exercise program is the best initial management for claudication due to peripheral artery disease (PAD). For patients with persistent symptoms despite smoking cessation, antiplatelet and statin therapy, and supervised exercise therapy, the addition of twice-daily cilostazol may lead to improvement in symptoms.
What medication is used for persistent claudication despite exercise therapy?
Cilostazol (a phosphodiesterase inhibitor that improves walking distance). Cilostazol is a phosphodiesterase-3 inhibitor that provides symptomatic improvement in some patients with claudication due to PAD; however, initiation of the drug is not recommended until lifestyle modifications (eg, smoking cessation, exercise) have failed.
What are the indications for revascularization in PAD?
Disabling claudication refractory to medical therapy or limb-threatening ischemia. Even when the stenosis is shown to be at 80-90% on angiograms, these measures are not pursued until other interventions have been performed. The only exception would be a threatened limb.
What are the revascularization options for PAD?
Endovascular angioplasty with stenting or surgical bypass.
What complication can PAD lead to if untreated?
Critical limb ischemia and possible amputation.
What is the recommended algorithm for working up PAD?
Start with ABI, then perform CT/MR angiography if needed, followed by angioplasty with stenting or bypass if severe.
