Peripheral Artery Disease

Question 1

Arterial Blood Vessel Disorders (10)

Answer 1

Peripheral Artery Disease
Atherosclerotic Vascular Disease
Nonatherosclerotic Vascular Disease
Acute Arterial Occlusion of a Limb
Thoracic Outlet Compression Syndrome
Peripheral Artery Aneurysms
Raynaud’s Phenomenon
Acrocyanosis
Livedo Reticularis
Chilbain’s Syndrome

Question 2

Peripheral Artery Disease (4)

Answer 2

A clinical disorder in which there is a stenosis or occlusion in the aorta or the arteries of the limbs.
Leading cause of PAD in patients >40yrs old:
Atherosclerosis
Highest prevalence occurs in the 6th/7th decades of life

Question 3

Other Causes of PAD (6)

Answer 3

Thrombosis
Embolism
Vasculitis (Giant Cell and Takayasu’s arteritis)
Fibromuscular dysplasia
Entrapment
Trauma

Question 4

Increase risk of PAD if : (6)

Answer 4

Cigarette smoker (most modifiable risk factor)
DM: prevalence in Diabetics is around 24%, in contrast to 8% in non-diabetics
Hypercholesterolemia (low HDL, high TC, high LDL, etc)
HTN- tx of HTN alone will not decrease risk of PAD
Hyperhomocysteinemia- leads to atherosclerosis and PAD

Question 5

Primary Sites of Atherosclerotic PAD (3)

Answer 5

Abdominal aorta and iliac arteries
Femoral and popliteal arteries-most common
More distal vessels (tibial and peroneal arteries)

Question 6

Atherosclerotic PAD Clinical evaluation (3)

Answer 6

<50% are symptomatic
Most common symptom is Claudication
Pain, ache, cramp, numbness or a sense of fatigue in the muscles that occurs during exercise and is relieved w/ rest.
Site of claudication is always distal to the site of the lesion
Ex. Calf claudication (femoral/popliteal dz)
Develops at different distances depending on the degree of occlusion and stenosis

Question 7

Atherosclerotic PAD- PE Findings (7)

Answer 7

Decreased or absent pulses distal to the obstruction
Presence of a bruit over the narrowed artery
Muscle atrophy distal from the site of the lesion
Severe disease:
Hair loss
Thickened nails
Smooth and shiny skin
Reduced skin temp
Pallor or cyanosis

Question 8

Noninvasive Diagnostic testing for PAD Ankle: brachial index (ABI)

Answer 8

Ankle: brachial index (ABI)-
Measure the SBP in the legs and compare it to the arms (ABI)
Arms and legs should be either equal or ankle>brachial, therefore ABI should be ≥ 1.0 in normal individuals
In the presence of stenosis, SBP in the legs is decreased
<0.5 in pts w/ severe PAD
Performed w/ Doppler U/S to look at the waveform analysis following a low ABI: shows blunting of the waveform in the presence of PAD

Question 9

Sites of Disease for PAD

Answer 9

Aortoiliac
Femoral/Popliteal
Lower leg/foot

Question 10

Noninvasive Diagnostic Testing for PAD

Answer 10

Treadmill testing: objective assessment of functional limitations
Decline of ABI immediately after exercise provides further support for the diagnosis of PAD
Duplex Doppler Ultrasound
Produces an image of the vessel (anatomy) & the surrounding tissue
Able to assess the speed and direction of blood flow through a vessel
Mostly useful in medium sized and superficial arteries, not for distal small ones.
MRA, CTA and conventional contrast angiography are not used for routine diagnostic testing. Reserved only if symptoms require revascularization

Question 11

Aortoiliac Artery Disease

Atherosclerotic PAD

Answer 11

Claudication occurs in the calves, thighs and/or buttocks
Femoral pulses and distal pulses are absent or weak
Bruit may be heard over the aorta, iliac or femoral arteries, or all 3
ABI will be decreased throughout the entire lower extremity

Question 12

Aortoiliac Artery Disease Treatment

Atherosclerotic PAD

Answer 12

Conservative
Endovascular surgery- angioplasty/stenting (when segmental or single stenosis)
Surgery (bypass grafting)
When to Refer to a vascular surgeon:
Progressive reduction in walking distance
Limiting ADL’s

Question 13

Femoral/Popliteal Artery Disease

Atherosclerotic PAD

Answer 13

Superficial femoral artery is the most common artery occluded by atherosclerosis
Symptoms will be confined to calf
May see atrophic changes in the lower leg and foot
Femoral pulse is normal, decreased pulses in popliteal and pedal pulses

Question 14

Femoral/Popliteal Arteries Treatment

Atherosclerotic PAD

Answer 14

Tx:
Conservative
Surgery (Bypass-most common)- mandatory if rest pain or threatened tissue
Angioplasty +/- stenting
Thromboendarterectomy- limited to common femoral artery dz
When to Refer:
Progressive symptoms, short distance claudication, rest pain or if any ulcerations are present

Question 15

Lower leg/Foot Arterial Disease

Atherosclerotic PAD

Answer 15

Primarily involves tibial vessels
DM is a major risk factor
Rest pain is confined to dorsum of foot and relieved w/ dependency
Pain is severe, burning and may awaken pt from sleep
Skin is cool, atrophic and hairless
Pedal pulses are absent

Question 16

Lower leg/Foot Arterial Disease Treatment

Atherosclerotic PAD

Answer 16

Treatment (goal is to prevent tissue loss):
Conservative- good foot care
Surgery- required if rest pain at night w/ low ABI/monophasic wave forms to prevent tissue loss
Bypass- primary technique for revascularization to preserve limb
Amputation (necrotic or severely infected tissue):
When to Refer to a Vascular Surgeon:
If pedal pulses are even slightly weak/reduced and if any ulcers are present (regardless of size)

Question 17

Goals of Treatment in all PAD

Answer 17

Management Goals:
Improve ability to walk
Prevent the Progression to Limb Ischemia and Amputation

Question 18

Conservative Treatment for all patients w/ PAD

Answer 18

SMOKING CESSATION!!!
Risk factor reduction
Control BP in hypertensive pts (ACEI recommended)
Lower cholesterol w/ a statin (goal LDL <100)
Weight loss
Treat DM aggressively
Platelet inhibitors (ASA/Clopidogrel) reduces the risk of adverse CV events in pts w/ PAD (Stroke/MI) but does not tx symptoms
Consistent/moderate exercise (improves walking distance)- minimum of 30 minutes a day
Foot Care
Keep clean and protected against excessive drying
Well-fitted and protective shoes to reduce trauma
Avoid support hose/compressive stockings- reduces blood flow to the skin

Question 19

Prognosis for Atherosclerotic PAD

Answer 19

Depends on the patients medical hx (the extent of coexisting coronary and cerebrovascular disease)
Pts w/ PAD have a 15-30% 5 year mortality rate and a 2 to 6-fold increased risk of death from coronary heart disease
25-30% of pts w/ critical limb ischemia undergo amputation w/in 1 year
Prognosis is worse in pts who continue to smoke or have DM

Question 20

Fibromuscular Dysplasia

Answer 20

Hyperplastic disorder
Results in stenosis and aneurysms of medium and small sized arteries—> HTN, dissections, claudication and rest pain if limb vessels are involved
Usually involves the renal and carotid arteries but can affect blood vessels in extremities
Predominantly in females, early 50’s
Increased risk in smokers

Question 21

Fibromuscular Dysplasia Diagnosis and Treatment

Answer 21

Diagnosed angiographically by a “string of beads” appearance
S&S are similar to those for atherosclerosis when limb vessels are involved (claudication and rest pain)
Treatment is similar to PAD in pts w/ severe symptoms and/or threatened tissue loss

Question 22

Thromboangiitis Obliterans

Answer 22

Aka “Buerger’s disease”
Inflammatory occlusive vascular d/o involving small and medium sized arteries and veins in the distal upper and lower extremities only
Most frequently occurs in men >40yrs
Prevalence higher in Asians and pts of Eastern European descent
Cause is unknown, but cigarette smoking may play a role

Question 23

Triad for Thromboangiitis Obliterans

Answer 23

claudication of affected extremity
Raynaud’s phenomenon and
migratory superficial vein thrombophlebitis

Question 24

Thromboangiitis Obliterans Diagnosis and Treatment

Answer 24

Claudication confined to calves/feet and forearms/hands
If severe digital ischemia is present:
Trophic nail changes, painful ulcerations and gangrene may develop to tips of digits
Normal brachial and popliteal pulses but reduced or absent radial, ulnar and/or tibial pulses
Diagnosis confirmed by bx of involved vessel
No specific tx except smoking cessation
Arterial bypass of the larger vessels if possible, local debridement and amputation if required

Question 25

Takayasu’s Arteritis

Answer 25

Inflammatory and stenotic dz of medium and large sized arteries Strong predilection for the aortic arch and its branches (“aortic arch syndrome”) Can affect the iliac artery resulting in leg claudication symptoms Uncommon (incidence rate of 1.2-1.6 cases/million) Most prevalent in adolescent girls and young women Most common in Asia but can occur anywhere

Question 26

Takayasu’s Arteritis Diagnosis and Treatment

Answer 26

Diagnosis: Arteriography-confirms the diagnosis (characteristic pattern) Irregular vessel walls, stenosis, poststenotic dilatation, aneurysm formation, occlusion and evidence of increased collateral circulation Treatment Glucocorticoid therapy may relieve acute symptoms, but does not treat the condition Surgical: to decrease the mortality rate

Question 27

Giant Cell Arteritis

Answer 27

AKA “temporal arteritis” Inflammation of medium and large sized arteries Characteristically involves one or more branches of the carotid artery, particularly the temporal artery Systemic disease; therefore can affect involve arteries in multiple locations Strongly associated w/ Polymyalgia Rheumatica (PMR) Seen in 40-50% of patients w/ giant cell arteritis Occurs exclusively in patients >50yrs old More common in women than men

Question 28

Clinical Signs/ Symptoms of Giant Cell Arteritis

Answer 28

Complex of fever, anemia, high ESR and HA’s in a pt over 50y Systemic symptoms: malaise/fatigue, anorexia, wt loss, sweats, arthralgias, PMR or large vessel dz If involving cranial arteries- HA is most common w/ a tender, thickened, or nodular artery, scalp pain, claudication of the jaw/tongue, ischemic optic neuropathy (could lead to blindness) If involving large vessels- subclavian artery stenosis arm claudication; aortic aneurysms (risk of rupture and dissection); leg claudication w/ diminished pulses or bruits

Question 29

Labs/Diagnosis/Treatment of Giant Cell Arteritis

Answer 29

``` Labs Elevated ESR (non-specific) ``` Diagnosis: Confirmed by biopsy of the temporal artery Should be obtained as quickly as possible and therapy should not be delayed pending the bx results If large vessel disease, confirm by vascular imaging (MRA, CTA) Treatment: Goal- reduce symptoms and prevent visual loss Glucocorticoid treatment is the gold standard tx High dose Prednisone for 1 month followed by gradual tapering

Question 30

Acute Arterial Occlusion of a Limb

Answer 30

Results in the sudden loss of blood flow to an extremity The size/extent of the occlusion and development of collateral blood flow determines the signs/symptoms, the degree of ischemia and the viability of the extremity

Question 31

2 causes: of Embolism and Primary Thrombosis

Answer 31

Embolism Most common sources of arterial emboli are : heart, aorta and large arteries A. fib is the most common cause Primary Thrombosis: Pts usually have a hx of claudication and now have an acute occlusion

Question 32

Clinical Features of Acute Arterial Occlusion of a Limb (6)

Answer 32

``` 6 P’s: Sudden onset of pain Pallor Pulselessness Paresthesias Poikilothermia (coolness) Paralysis If occurs in the presence of an adequate collateral circulation Symptoms will be less impressive Sudden decrease in the distance walked before claudication occurs or of pain and paresthesia ```

Question 33

Diagnosis of Acute Arterial Occlusion of a Limb

Answer 33

Clinical diagnosis Doppler U/S to assess blood flow- little or none Imaging (MRA, CTA or catheter-based arteriography)- abrupt cutoff of contrast

Question 34

Treatment of Acute Arterial Occlusion of a Limb

Answer 34

If limb is in jeopardy: Immediate revascularization w/in 3 hours along w/ Heparin IV to prevent clot propagation If limb is not in jeopardy: Conservative tx Observation and anticoagulants (prevents recurrent embolism and reduce the likelihood of clot propagation) Heparin IV followed by oral warfarin Endovascular Surgery (catheter directed chemical thrombolysis into the clot)

Question 35

Prognosis of Acute Arterial Occlusion of a Limb

Answer 35

10-25% risk of amputation w/ acute arterial occlusion from emboli Prognosis for acute thrombotic occlusion is better d/t collateral flow

Question 36

Thoracic Outlet Compression Syndrome Etiology

Answer 36

Compression of the neurovascular bundle (artery, vein or nerves) at the thoracic outlet as it courses through the neck/shoulder Causes: Cervical ribs Abnormalities of muscles or their insertion Proximity of clavicle to the first rib

Question 37

Thoracic Outlet Compression Syndrome

Answer 37

Combination of 4 symptoms in the upper extremity Pain, numbness, weakness and swelling Depends on what structures are being compressed Vascular symptoms: Arterial ischemia- pallor of fingers on elevation of the extremity, sensitivity to cold and rarely gangrene of the digits Venous obstruction- edema, cyanosis and engorgement Symptoms can be provoked w/in 60sec >90% of the time by having the patient elevate the arms Wright’s Maneuver Adson’s Test

Question 38

Wright’s Maneuver (hyperabduction test)

Answer 38

The radial pulse weakens or disappears when the arm is abducted and externally rotated on the affected side

Question 39

Adson’s Test

Answer 39

Radial pulse weakens or disappears when the patient rotates their head to the affected side with extended neck following deep inspiration.

Question 40

Ddx and Diagnosis for Thoracic Outlet Compression Syndrome

Answer 40

DDx: OA of the spine Tumors of the lung, spinal cord or nerve roots Periarthritis of the shoulder Diagnosis: CXR: identifies cervical rib MRI: w/ arm held in a certain position Angiography (arterial/venous obstruction)

Question 41

Treatment of Thoracic Outlet Compression Syndrome

Answer 41

``` 95% treated successfully w/ conservative tx PT and avoiding aggravating positions/activities Operative tx (<5%) ```

Question 42

Peripheral Artery Aneurysm

Answer 42

Popliteal artery aneurysms are the most common (70%) 50% are b/l Tend to embolize repetitively over time and occlude arteries Most common presentation is limb ischemia secondary to thrombosis or embolism 1/3 of patients require amputation To prevent limb loss, repair should be performed if the aneurysm is >2cm in diameter or if they are symptomatic

Question 43

Clinical Findings for Peripheral Artery Aneurysm

Answer 43

If in groin, may feel a pulsatile mass Popliteal aneurysms are often undetected First symptoms may be d/t ischemia Range from sudden onset pain and paralysis to short distance claudication that slowly lessens as collateral flow develops Recurrent pain in the foot w/ cyanosis suggests embolization and requires a thorough work up

Question 44

Imaging and Treatment for Peripheral Artery Aneurysm

Answer 44

``` Imaging: Duplex U/S- gold standard MRA/CTA is required for reconstruction Treatment: Surgery if symptomatic, if aneurysm measures >2cm in diameter or if a thrombus is present w/in the aneurysm ```

Question 45

Raynaud’s Phenomenon

Answer 45

Syndrome of paroxysmal digital ischemia Most commonly caused by an exaggerated digital arteriole vasoconstriction to cold or emotional stress Initial phase: excessive vasoconstriction resulting in digital pallor or cyanosis Recovery phase: vasodilation resulting in intense hyperemia (increased blood flow) and rubor Primarily affects the fingers, but can affect toes Thumbs are rarely affected

Question 46

Signs/ Symptoms of Raynaud’s Phenomenon

Answer 46

One or more digits appear white when exposed to cold (pallor/cyanosis) During recovery phase, may get intense rubor, throbbing, paresthesias, pain and slight swelling Attacks usually resolve spontaneously or upon rewarming

Question 47

Primary Type of Raynaud’s Phenomenon

Answer 47

``` 2-6% of adults More common in young women Appears first b/w ages 15-30yr Mildly progressive Symmetric involvement is the rule ```

Question 48

Secondary Type of Raynaud’s Phenomenon

Answer 48

Less common Associated w/ rheumatic disease Nailfold capillary abnormalities may be 1st clue Causes digital pitting, ulceration and/or gangrene

Question 49

Treatments for Raynaud’s Phenomenon

Answer 49

Treatment of Primary RP General: Keep body warm (prevent reflex vasospasms) Wear gloves/mittens in cold weather Protect hands from injury at all times Treat dry skin Smoking cessation Avoid sympathomimetic drugs (decong, diet pills, etc) Medications (severe cases): Calcium Channel Blocker (CCB)- first line Α-adrenergic antagonists Treatment of Secondary RP General measures above Treat the underlying illness (rheumatology consult)

Question 50

Acrocyanosis

Answer 50

Arterial vasoconstriction and secondary dilation of the capillaries and venules resulting in persistent (not episodic) cyanosis of the hands and occasionally the feet Cyanosis is worse when exposed to the cold

Question 51

Primary Acrocyanosis

Answer 51

Women >men, age of onset <30yrs Asymptomatic, but seek tx d/t cosmetic reasons Pain, ulcers and gangrene do not occur Exam- normal pulses, cyanosis and moist palms, blanching does not occur Tx- reassurance, dress warmly and avoid cold exposure

Question 52

Primary and Secondary Livedo Reticularis

Answer 52

Localized areas of the extremities develop a mottled (net-like) appearance of reddish/blue discoloration that is more prominent after cold exposure Primary (idiopathic): Benign, but may be associated w/ ulcerations Women>men Age of onset, 3rd decade of life Asymptomatic (seek eval d/t cosmetic reasons) Tx: Reassure and avoid cold environments Secondary: d/t underlying d/o Ulcerations do not occur Tx underlying d/o

Question 53

Pernio (Chilbains)

Answer 53

Vasculitis d/o associated w/ exposure to cold Most commonly occurs in young women, but may occur in adults and children Raised erythematous lesions develop on the distal lower extremities in cold weather Usually self-limiting but may lead to recurrent disease Associated w/ pruritis, burning sensation and/or pain May ulcerate and blister

Question 54

Pernio (Chilbains) Treatment

Answer 54

Avoid exposure to cold Wound care over ulcers Sympatholytic agents and dihydropyridine CCB may be effective (ex. Nifedipine which produces vasodilation)