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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
Who is Thromboangiitis Obliterans more frequent in
Most frequently occurs in men >40yrs | Prevalence higher in Asians and pts of Eastern European descent
26
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
27
Thromboangiitis Obliterans TX
No specific tx except smoking cessation | Arterial bypass of the larger vessels if possible, local debridement and amputation if required
28
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
29
Takayasu’s Arteritis most prevalent in
Most prevalent in adolescent girls and young women | Most common in Asia but can occur anywhere
30
Takayasu’s Arteritis Generalized symptoms 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
31
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
32
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
33
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
34
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
35
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)
36
Who does GIant Cell arteritis affect
Occurs exclusively in patients >50yrs old | More common in women than men
37
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
38
how is Giant cell arteritis diagnosed
biopsy of the temporal artery | If large vessel disease should be confirmed by vascular imaging
39
What is the TX of Giant cell arteritis
Glucocorticoid treatment is the gold standard tx | Goal- reduce symptoms and prevent visual loss
40
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
41
Acute Arterial Occlusion of a Limb 2 causes
Embolism and Primary Thrombosis
42
Most common sources of arterial emboli are
Atrial fib is the most common cause | heart, aorta and large arteries
43
Acute Arterial Occlusion of a Limb 6 P's
``` Sudden onset of pain Pallor Pulselessness Paresthesias Poikilothermia (coolness) Paralysis ```
44
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
45
Acute arterial occlusion TX
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: ex anticoagulant
46
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
47
Thoracic outlet compression syndrome
Compression of the neurovascular bundle (artery, vein or nerves) at the thoracic outlet as it courses through the neck/shoulder Caused by: Cervical ribs Abnormalities of muscles or their insertion Proximity of clavicle to the first rib
48
Thoracic outlet compression syndrome symptoms
Pain, numbness, weakness and swelling 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
49
Thoracic outlet compression syndrome Treatment
``` 95% treated successfully w/ conservative tx PT and avoiding aggravating positions/activities Operative tx (<5%) ```
50
Peripheral Artery Aneurysm
Popliteal artery aneurysms are the most common (70%) Most common presentation is limb ischemia secondary to thrombosis or embolism To prevent limb loss, repair should be performed if the aneurysm is >2cm in diameter or if they are symptomatic
51
Peripheral artery aneurysm signs clinical finding
If in groin, may feel a pulsatile mass Popliteal aneurysms are often undetected 1st symptoms may be ischemia
52
Peripheral artery aneurysm
Surgery if symptomatic, if aneurysm measures >2cm in diameter or if a thrombus is present w/in the aneurysm
53
Raynaud’s Phenomenon
Syndrome of paroxysmal digital ischemia | Most commonly caused by an exaggerated digital arteriole vasoconstriction to cold or emotional stress
54
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
55
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
56
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 ```
57
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 ```
58
Acrocyanosis
Arterial vasoconstriction and secondary dilation of the capillaries and venules resulting in persistent (not episodic) cyanosis of the hands and occasionally the feet
59
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
60
Acrocyanosis TX
Tx- reassurance, dress warmly and avoid cold exposure
61
Livedo Reticularis
Localized areas of the extremities develop a mottled (net-like) appearance of reddish/blue discoloration that is more prominent after cold exposure
62
Livedo Reticularis
Women>men Age of onset, 3rd decade of life Asymptomatic (seek eval d/t cosmetic reasons) Tx: Reassure and avoid cold environments
63
Pernio (Chilbains)
Vasculitis d/o associated w/ exposure to cold | Most commonly occurs in young women, but may occur in adults and children
64
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
65
Pernio (Chilbains) Tx
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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