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Clin Med-Cardiology Exam 1 > Peripheral Artery Disease > Flashcards

Peripheral Artery Disease Flashcards

1
Q

PAD disease

A

A clinical disorder where there is a stenosis or occlusion in the aorta or distal arteries of the limbs

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2
Q

What is the leading cause of PAD in patient >40yo

A

Atherosclerosis

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3
Q

when is the highest prevalence of atherosclerotic PAD

A

6th/7th decades of life

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4
Q

What increases the risk of Atherosclerotic PAD

A 
Cigarette smoker
DM
Hypercholesterolemia
HTN
Hyperhomocysteinemia
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5
Q

Where does atherosclerosis usually occur

A

in arterial branch sites of
Increased turbulance
Altered shear stress
Intimal injury

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6
Q

What is the most common site of atherosclerotic PAD

A

Femoral and popliteal arteries
Can also affect:
Abdominal aorta and iliac arteries

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7
Q

What is the most common symptom of Atherosclerotic PAD

A

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

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8
Q

Atherosclerotic PAD- PE Findings

A

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

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9
Q

Atherosclerotic PAD noninvasive testing

A

Ankle:brachial index (ABI)
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

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10
Q

Aortoiliac Artery Disease Tx

A

Conservative
Endovascular surgery- angioplasty/stenting (when segmental or single stenosis)
Surgery (bypass grafting

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11
Q

When to Refer to a vascular surgeon

A

Progressive reduction in walking distance

Limiting ADL’s

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12
Q

Femoral/Popliteal Artery Disease

A

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

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13
Q

Femoral/Popliteal Arteries Tx:

A

Conservative
Surgery (Bypass-most common)- mandatory if rest pain or threatened tissue
Angioplasty +/- stenting
Thromboendarterectomy- limited to common femoral artery dz

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14
Q

Lower leg/Foot Arterial Disease symptoms

A

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

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15
Q

Lower leg/Foot Arterial Disease TX

A

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)

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16
Q

Lower leg/Foot Arterial Disease when to refer to vascular surgeon

A

If pedal pulses are even slightly weak/reduced and if any ulcers are present (regardless of size)

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17
Q

Goals of Treatment in all PAD

A

Improve ability to walk

Prevent the Progression to Limb Ischemia and Amputation

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18
Q

What is the conservative TX for all patients w/ PAD

A

SMOKING CESSATION!!!
Risk factor reduction- control BP, lower cholesterol, weight loss, treat DM

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19
Q

Athersclerotic PAD prognosis

A

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

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20
Q

Fibromuscular Dysplasia

A

Hyperplastic disorder
Results in stenosis and aneurysms of medium and small sized arteries HTN, dissections, claudication and rest pain if limb vessels are involved

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21
Q

What does Fibromuscular Dysplasia affect

A

Usually involves the renal and carotid arteries but can affect blood vessels in extremities

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22
Q

Fibromuscular Dysplasia diagnosed how

A

angiographically by a “string of beads” appearance

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23
Q

Fibromuscular Dysplasia S&S and Tx

A

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

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24
Q

Thromboangiitis Obliterans

A

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

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25
Q

Who is Thromboangiitis Obliterans more frequent in

A

Most frequently occurs in men >40yrs

Prevalence higher in Asians and pts of Eastern European descent

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26
Q

Thromboangiitis Obliterans S&S triad

A

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

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

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27
Q

Thromboangiitis Obliterans TX

A

No specific tx except smoking cessation

Arterial bypass of the larger vessels if possible, local debridement and amputation if required

28
Q

Takayasu’s Arteritis

A

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

29
Q

Takayasu’s Arteritis most prevalent in

A

Most prevalent in adolescent girls and young women

Most common in Asia but can occur anywhere

30
Q

Takayasu’s Arteritis Generalized symptom s

Vascular symptoms

A

General sym: malaise, fever, night sweats, arthralgias, anorexia and wt loss
May occur months before vascular involvement is evident

Vascular symp: related to vascular compromise and organ ischemia, pulses absent in the involved vessels, HTN is present in 32-93% of patients

31
Q

Who should you suspect Takayasu’s Arteritis in?

A

Should be suspected in young women who develop decreased or absent pulses, BP changes and arterial bruits

32
Q

Takayasu’s associated with

A

increased morbidity and mortality
Secondary to disease related illness (CHF, CVA, MI, aneurysm rupture or renal failure)
Course of the illness is variable, most often chronic and relapsing

33
Q

Takayasu’s is diagnosed by

A

Arteriography-confirms the diagnosis (characteristic pattern)
Irregular vessel walls, stenosis, poststenotic dilatation, aneurysm formation, occlusion and evidence of increased collateral circulation

34
Q

what is the treatment for Takayasu’s arteritis

A

Glucocorticoid therapy may relieve acute symptoms, but does not treat the condition
Surgical: to decrease the mortality rate

35
Q

Giant cell arteritis

A

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)

36
Q

Who does GIant Cell arteritis affect

A

Occurs exclusively in patients >50yrs old

More common in women than men

37
Q

Giant cell arteritis clinical S/S

A

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

38
Q

how is Giant cell arteritis diagnosed

A

biopsy of the temporal artery

If large vessel disease should be confirmed by vascular imaging

39
Q

What is the TX of Giant cell arteritis

A

Glucocorticoid treatment is the gold standard tx

40
Q

Acute Arterial Occlusion of a Limb

A

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

41
Q

Acute Arterial Occlusion of a Limb 2 causes

A

Embolism and Primary Thrombosis

42
Q

Most common sources of arterial emboli are

A

Atrial fib is the most common cause

43
Q

Acute Arterial Occlusion of a Limb 6 P’s

A 
Sudden onset of pain
Pallor
Pulselessness
Paresthesias
Poikilothermia (coolness)
Paralysis
44
Q

Acute Arterial Occlusion diagnosed by

A

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

45
Q

Acute arterial occlusion TX

A

If limb is in jeopardy: Immediate revascularization w/in 3 hours along w/ Heparin IV to prevent clot propagation

46
Q

What is the prognosis of Acute arterial occlusion of a limb

A

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

47
Q

Thoracic outlet compression syndrome

A

Compression of the neurovascular bundle (artery, vein or nerves) at the thoracic outlet as it courses through the neck/shoulder

48
Q

Thoracic outlet compression syndrome symptoms

A

Pain, numbness, weakness and swelling

49
Q

Thoracic outlet compression syndrome Treatment

A 
95% treated successfully w/ conservative tx
PT and avoiding aggravating positions/activities
Operative tx (<5%)
50
Q

Peripheral Artery Aneurysm

A

Popliteal artery aneurysms are the most common (70%)
Most common presentation is limb ischemia secondary to thrombosis or embolism

51
Q

Peripheral artery aneurysm signs clinical finding

A

If in groin, may feel a pulsatile mass
Popliteal aneurysms are often undetected
1st symptoms may be ischemia

52
Q

Peripheral artery aneurysm

A

Surgery if symptomatic, if aneurysm measures >2cm in diameter or if a thrombus is present w/in the aneurysm

53
Q

Raynaud’s Phenomenon

A

Syndrome of paroxysmal digital ischemia

Most commonly caused by an exaggerated digital arteriole vasoconstriction to cold or emotional stress

54
Q

Raynaud’s Phenomenon 2 phases

A

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

55
Q

Raynaud’s Phenomenon signs and symptoms

A

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

56
Q

what are the 2 types of Raynaud’s phenomenom

A 
primary:More common in young women
Appears first b/w ages 15-30yr
Mildly progressive
Symmetric involvement is the rule
Secondary:
Less common 
Associated w/ rheumatic disease
Nailfold capillary abnormalities may be 1st clue
Causes digital pitting, ulceration and/or gangrene
57
Q

Raynaud’s Phenomenon Tx

A 
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 
Medications (severe cases):
Calcium Channel Blocker (CCB)- first line
58
Q

Acrocyanosis

A

Arterial vasoconstriction and secondary dilation of the capillaries and venules resulting in persistent (not episodic) cyanosis of the hands and occasionally the feet

59
Q

acrocyanosis who it effects

A

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

60
Q

Acrocyanosis TX

A

Tx- reassurance, dress warmly and avoid cold exposure

61
Q

Livedo Reticularis

A

Localized areas of the extremities develop a mottled (net-like) appearance of reddish/blue discoloration that is more prominent after cold exposure

62
Q

Livedo Reticularis

A

Women>men
Age of onset, 3rd decade of life
Asymptomatic (seek eval d/t cosmetic reasons)
Tx: Reassure and avoid cold environments

63
Q

Pernio (Chilbains)

A

Vasculitis d/o associated w/ exposure to cold

Most commonly occurs in young women, but may occur in adults and children

64
Q

Pernio (Chilbains) presentation

A

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

65
Q

Pernio (Chilbains) Tx

A

Avoid exposure to cold
Wound care over ulcers
Sympatholytic agents and dihydropyridine CCB may be effective

Clin Med-Cardiology Exam 1 (8 decks)

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