Peripheral Artery Disease Flashcards
PAD disease
A clinical disorder where there is a stenosis or occlusion in the aorta or distal arteries of the limbs
What is the leading cause of PAD in patient >40yo
Atherosclerosis
when is the highest prevalence of atherosclerotic PAD
6th/7th decades of life
What increases the risk of Atherosclerotic PAD
Cigarette smoker DM Hypercholesterolemia HTN Hyperhomocysteinemia
Where does atherosclerosis usually occur
in arterial branch sites of
Increased turbulance
Altered shear stress
Intimal injury
What is the most common site of atherosclerotic PAD
Femoral and popliteal arteries
Can also affect:
Abdominal aorta and iliac arteries
What is the most common symptom of Atherosclerotic PAD
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
Atherosclerotic PAD- PE Findings
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
Atherosclerotic PAD noninvasive testing
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
Aortoiliac Artery Disease Tx
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
Femoral/Popliteal Artery Disease
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
Femoral/Popliteal Arteries Tx:
Conservative
Surgery (Bypass-most common)- mandatory if rest pain or threatened tissue
Angioplasty +/- stenting
Thromboendarterectomy- limited to common femoral artery dz
Lower leg/Foot Arterial Disease symptoms
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
Lower leg/Foot Arterial Disease TX
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)
Lower leg/Foot Arterial Disease when to refer to vascular surgeon
If pedal pulses are even slightly weak/reduced and if any ulcers are present (regardless of size)
Goals of Treatment in all PAD
Improve ability to walk
Prevent the Progression to Limb Ischemia and Amputation
What is the conservative TX for all patients w/ PAD
SMOKING CESSATION!!!
Risk factor reduction- control BP, lower cholesterol, weight loss, treat DM
Athersclerotic PAD prognosis
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
Fibromuscular Dysplasia
Hyperplastic disorder
Results in stenosis and aneurysms of medium and small sized arteries HTN, dissections, claudication and rest pain if limb vessels are involved
What does Fibromuscular Dysplasia affect
Usually involves the renal and carotid arteries but can affect blood vessels in extremities
Fibromuscular Dysplasia diagnosed how
angiographically by a “string of beads” appearance
Fibromuscular Dysplasia S&S and Tx
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
Thromboangiitis Obliterans
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
Who is Thromboangiitis Obliterans more frequent in
Most frequently occurs in men >40yrs
Prevalence higher in Asians and pts of Eastern European descent
Thromboangiitis Obliterans S&S triad
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
Thromboangiitis Obliterans TX
No specific tx except smoking cessation
Arterial bypass of the larger vessels if possible, local debridement and amputation if required
Takayasu’s Arteritis
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
Takayasu’s Arteritis most prevalent in
Most prevalent in adolescent girls and young women
Most common in Asia but can occur anywhere
Takayasu’s Arteritis Generalized symptom s
Vascular symptoms
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
Who should you suspect Takayasu’s Arteritis in?
Should be suspected in young women who develop decreased or absent pulses, BP changes and arterial bruits
Takayasu’s associated with
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
Takayasu’s is diagnosed by
Arteriography-confirms the diagnosis (characteristic pattern)
Irregular vessel walls, stenosis, poststenotic dilatation, aneurysm formation, occlusion and evidence of increased collateral circulation
what is the treatment for Takayasu’s arteritis
Glucocorticoid therapy may relieve acute symptoms, but does not treat the condition
Surgical: to decrease the mortality rate
Giant cell arteritis
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)
Who does GIant Cell arteritis affect
Occurs exclusively in patients >50yrs old
More common in women than men
Giant cell arteritis clinical S/S
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
how is Giant cell arteritis diagnosed
biopsy of the temporal artery
If large vessel disease should be confirmed by vascular imaging
What is the TX of Giant cell arteritis
Glucocorticoid treatment is the gold standard tx
Acute Arterial Occlusion of a Limb
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
Acute Arterial Occlusion of a Limb 2 causes
Embolism and Primary Thrombosis
Most common sources of arterial emboli are
Atrial fib is the most common cause
Acute Arterial Occlusion of a Limb 6 P’s
Sudden onset of pain Pallor Pulselessness Paresthesias Poikilothermia (coolness) Paralysis
Acute Arterial Occlusion diagnosed by
Clinical diagnosis
Doppler U/S to assess blood flow- little or none
Imaging (MRA, CTA or catheter-based arteriography)- abrupt cutoff of contrast
Acute arterial occlusion TX
If limb is in jeopardy: Immediate revascularization w/in 3 hours along w/ Heparin IV to prevent clot propagation
What is the prognosis of Acute arterial occlusion of a limb
10-25% risk of amputation w/ acute arterial occlusion from emboli
Prognosis for acute thrombotic occlusion is better d/t collateral flow
Thoracic outlet compression syndrome
Compression of the neurovascular bundle (artery, vein or nerves) at the thoracic outlet as it courses through the neck/shoulder
Thoracic outlet compression syndrome symptoms
Pain, numbness, weakness and swelling
Thoracic outlet compression syndrome Treatment
95% treated successfully w/ conservative tx PT and avoiding aggravating positions/activities Operative tx (<5%)
Peripheral Artery Aneurysm
Popliteal artery aneurysms are the most common (70%)
Most common presentation is limb ischemia secondary to thrombosis or embolism
Peripheral artery aneurysm signs clinical finding
If in groin, may feel a pulsatile mass
Popliteal aneurysms are often undetected
1st symptoms may be ischemia
Peripheral artery aneurysm
Surgery if symptomatic, if aneurysm measures >2cm in diameter or if a thrombus is present w/in the aneurysm
Raynaud’s Phenomenon
Syndrome of paroxysmal digital ischemia
Most commonly caused by an exaggerated digital arteriole vasoconstriction to cold or emotional stress
Raynaud’s Phenomenon 2 phases
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
Raynaud’s Phenomenon signs and symptoms
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
what are the 2 types of Raynaud’s phenomenom
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
Raynaud’s Phenomenon Tx
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
Acrocyanosis
Arterial vasoconstriction and secondary dilation of the capillaries and venules resulting in persistent (not episodic) cyanosis of the hands and occasionally the feet
acrocyanosis who it effects
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
Acrocyanosis TX
Tx- reassurance, dress warmly and avoid cold exposure
Livedo Reticularis
Localized areas of the extremities develop a mottled (net-like) appearance of reddish/blue discoloration that is more prominent after cold exposure
Livedo Reticularis
Women>men
Age of onset, 3rd decade of life
Asymptomatic (seek eval d/t cosmetic reasons)
Tx: Reassure and avoid cold environments
Pernio (Chilbains)
Vasculitis d/o associated w/ exposure to cold
Most commonly occurs in young women, but may occur in adults and children
Pernio (Chilbains) presentation
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
Pernio (Chilbains) Tx
Avoid exposure to cold
Wound care over ulcers
Sympatholytic agents and dihydropyridine CCB may be effective
