Peripheral Artery Disease Flashcards
Define Peripheral artery disease
A disorder where there is a stenosis or occlusion in the aorta or distal arteries of the limbs
What is the most common cause of peripheral artery disease?
Atherosclerosis
Other than atherosclerosis what are causes of peripheral artery disease?
Thrombosis Embolism Vasculitis Fibromuscular dysplasia Entratpment trauma
The highest prevalence of atherosclerotic PAD occurs in the ______ decade of life?
6th/7th
What factors increase risk of atherosclerotic PAD
Cigarette smoker
DM
Hypercholesterolemia
HTN
What is the most modifiable of all the risk facotors of atherosclerotic PAD?
Cigarette smoking
What sized vessels is atherosclerotic PAD usually located in?
Large and medium sized-typically at branch sites
What are the 3 primary sites of involvement of atherosclerotic PAD?
Aortoiliac
Femoral/popliteal
Lower leg/foot (distal vessels)
Which of the 3 primary sites of involvement is most commonly effected by atherosclerotic PAD?
Femoral and popliteal
What percentage of Pt’s with Atherosclerotic PAD are symptomatic?
50%
What is the most common symptom of atherosclerotic PAD
Claudication-pain, ache, cramp, numbness or sense of fatigue during exercise and relieved with rest (intermittent claudication)
The site of claudication is always __________ to the site of the lesion?
Distal
What are the general PE findings of a patient with atherosclerotic PAD?
Decreased/absent pulse distal to obstruction
Presence of bruit over narrowed artery
Muscle atrophy distal to lesion
What are the general PE findings of a patient with SEVER atherosclerotic PAD?
Hair loss thickened nails smooth shiny skin reduced skin them pallor to skin
If pt has aortoiliac dz what would you expect to see?
a. claudication in calves and feet only
b. strong femoral pulses
c. decrease ABI throughout entire leg with decreased waveforms
C-Decreased ABI throughout entire leg with decreased waveforms
Where does claudication occur in aortoiliac artery disease?
Calves, thighs, or buttocks
Other than claudication what other signs/symptoms may occur in a pt with aortoiliac artery disease?
ED
femoral pulse and distal pulse absent/weak
bruit over aorta, iliac or femoral artery (or all 3)
ABI decrease throughout entire LE
What artery is the MOST common to be occluded by atherosclerosis?
Superficial femoral artery
What signs and symptoms will be found on a patient with Femoral/popliteal artery disease?
symptoms confined to calf
atrophic changes in lower leg and foot
femoral pulse is normal, decreased pulses in pop and pedal pulses
What signs and symptoms are specific to pt’s with lower leg/foot arterial disease?
rest pain confined to dorsum of foot and relived with dependency (hanging foot off side of bed)
pain is severe, burning and may awaken pt from sleep, skin is cool, atrophic and hairless
pedal pulses are absent
Which disease is a major risk factor for lower leg/foot arterial disease?
DM
What vessels are primarily involved in lower leg/foot arterial disease?
tibial vessels
What is a normal ABI?
greater than 1.0
In the presence of stenosis _____ in the legs is decreased
SBP
Patients with severe PAD have an ABI less than
0.5
What noninvasive testing can be done to determine extent of AsPAD?
Treadmill-assess claudication with exercise
Duplex Doppler US-useful in medium and superficial arteries
MRA, CTA prior to surgery
Management goals for ALL PAD?
Improve ability to walk/symptoms
Prevent progression
What can progression of PAD lead to?
limb ischemia and amputation
Conservative TX for ALL pt’s with PAD?
Smoking cessation!!! risk factor reduction -control BP/HTN (ACE-I) -Lower cholesterol w/ a statin (LDL goal less than 100) -Weight loss -tx DM aggressively Consistent moderate exercise foot care
T/f Patient with PAD should be prescribed compression stockings when their ABI goes below 0.5 (severe)
FALSE!!!! Never give a patient with PAD compression stockings!!!!! This reduces the blood flow to the skin.
What is the reasoning behind placing a patient with AsPAD on platelet inhibitors? (ASA/Clopidogrel)
They reduce the risk of CV events. If a patient has PAD they are likely to also have CAD. They do not reduce the symptoms of PAD.
What are tx options for aortoiliac artery dz?
Conservative Endovascular surgery-angioplasty/stenting Bypass graft (open surgery)
When is surgery indicated for a pt with aortoiliac artery dz?
When activities of daily living are limited-a progressive reduction in walking distance
What are tx options for femoral/popliteal arteries?
Conservative
Bypass most common -mandatory if there is rest pain/threatening issue
Angioplasty +/- stenting
Thromboendarterectomy-for common femoral artery dz only
When is surgery recommended for pt’s with femoral/popliteal artery occlusion?
Progressive symptoms, short distance claudication, rest pain or presence of ulcerations
What vessel, if occluded, is open for consideration of a thromboendarterectomy vs. more invasive surgery,
Common femoral artery because of it’s ease of access.
What are the tx options for lower leg/foot arterial disease?
Conservative - good foot care
Surgery-Bypass or amputation (severely compromised/necrotic foot)
When is surgery recommended in pt’s with lower leg/foot arterial disease?
If pedal pulses are even slightly weak/reduced and if any ulcers are present (regardless of size).
Define fibromuscular disorder?
A hyperplastic disorder which results in stenosis and aneurysms of medium and small sized arteries. This leads to HTN, dissection, claudication and rest pain if limb vessels are involved.
What arteries are most commonly involved in Fibromuscular Dysplasia (FD)?
Renal and carotid arteries
What is FD a rare cause of?
renal artery stenosis
Epidemiologically FD is most common in _____ ?
Females in their 30’s and 40’s
What are Signs and symptoms of FD?
Similar for Atherosclerosis
HTN if renal artery is involved
Renal angiography shows “string of beads”
Tx for FD?
Similar to PAD
If renal artery stenosis occurs-surgery is curative
What is Thromboangiitis Obliterans (TO) also known as
Buerger’s disease
Define T.O.?
Inflammatory occlusive vascular d/o involving small and medium sized arteries and veins in the detail upper and lower extremities only!!!
What is the traid of Buerger’s (TO)?
Claudication of affected extremity
Raynaud’s phenom.
Migratory superficial vein thrombophlebitis
Where is claudication confined to in Beurger’s Dz (TO)
Calves/feet/forearms and hands
S/S of Beurger’s Dz (TO)
-Claudication in calves/feet/forearms/hands
-If severe-digital ischemia
Reduced/absent radial, ulnar and/or tibial puses
How is T.O diagnosed?
bx of involved vessel
Tx for T.O.?
No specific tx besides smoking cessation
surgical-bypass of most proximal affected if possible, local debridement and amputation if required
What dz is an inflammatory and stonostic dz of medium and larged sized arteries and commonly affects the aortic arch and its branches and subclavian artery?
Takayasu’s arteritis
T/F Takayasu’s arteritis is rare?
T
What group is Takayasu’s arteritis most prevelant amongst?
Adolescent girls and young women
Asia
Patient presents to the office with generalized symptoms of malaise, fever, night sweats, arthralgias, anorexia. On PE you note decreased pulses in the LE as well as a BP difference of 15mmHg b/l. What test might you order to confirm the diagnosis?
Arteriography to confirm diagnosis of Takayasu’s artertitis.
What is the tx for Takayasu’s Arteritis?
Glucocorticoid tx relieves sx but not condition
Surgery-decreases mortality rate.
What are the vascular symptoms of Takayasu’s arteritis?
Claudication
decreased/absent pulses in involved vessels
HTN in 32-93% of pts
Bruits
BP different in B/l arms (greater than 10mmHg)
Does Takayasu’s arteritis ever effect veins?
NO
What are the 2 possible causes of Accute arterial occlusion of a limb?
Embolism (mc from Afib)
Thrombosis of an atherosclerotic segment
The ______ and ___________________ and development of collateral blood flow determines the signs/symptoms, the degree of ischemia and the viability of the extremity
size and extent of the occlusion
What are the 6 P’s of acute arterial occlusion of the lib?
sudden onset of PAIN PALLOR PULSELESSNESS PARASTHESIAS POIKILOTHERMIA (coolness) PARALYSIS
W/u for acute arterial occlusion of a limb?
Doppler US
MRA, CTA or cath arteriography imaging
Tx for acute arterial occlusion of a limb
If limb is in jeopardy - immediate revascularization w/in 3 hours
If limb is not in jeopardy (collateral circ. has occurred)-observation and anticoagulants (prevents recurrent embolism and reduces likelihood of clot propagation)
What is the risk of amputation w/ acute arterial occlusion from emboli?
10-25%
For which is the prognosis better for:
acute thrombotic occlusion or embolic occlusion and Why?
Acute thrombotic occlusion b/c collateral flow may occur.
Define thoracic outlet compression syndrome
Compression of neuromuscular bundle (VAN) at thoracic outlet as it courses through neck/shoulder
What are 3 causes of Thoracic outlet compression syndrome?
Cervical ribs
Abnormalities of muscle or insertion
Proximity of clavicle to first rib
What 4 s/sx are found in combination in the UE of a pt with Thoracic outlet compression?
Combo of 4 symptoms in UE:
- Pain
- Numbness
- Weakness
- Swelling
What are the Vascular sx of thoracic outlet compression syndrome?
Arterial ischemia-pallor of fingers on elevation of the extremity, sensitivity to cold and rarely gangrene of digits
Venous obstruction-edema, cyanosis, and engorgement
What action may relieve the symptoms of a patient with Thoracic outlet compression syndrome?
Lowering their arm (raising their arms worsens symptoms)
What special tests can be done to evaluate a patient with Thoracic Outlet compression syndrome?
Wright’s maneuver
Adson’s test
Which test is described as a test in which:
The radial pulse weakens or disappears when the arm is abducted and externally rotated on the affected side?
Wright’s test
Which test is described as a test in which:
The radial pulse weakens or disappears when the patient rotates their head to the affected side with extended neck following deep inspiration
Adson’s test
DDX for thoracic outlet compartment syndrome?
OA of the spine
tumors of the lung, spinal cord or nerve roots
Periarthritis of the shoulder
w/u for thoracic outlet compartment syndrome?
CXR-to identify cervical rib
MRI-w/arm in certain position
Angiography-arterial/venous obstruction
Tx for thoracic outlet compartment syndrome?
95% tx w/ conservative tx-PT and avoiding aggravating positions/actions Operative tx (Less than 5%)
What peripheral artery aneurysm is the most common?
Popliteal (70%)
What percentage of pt’s with popliteal aneurysm are found to have bilateral aneurysms?
50%
What is the most common presentation of a pt with peripheral artery aneurysm?
Limb ischemia secondary to thrombosis or embolism
What percentage of pt’s require amputation?
1/3
Patient presents to ER with painful cold L foot, decreased pallor, cyanosis. On US a 2.5cm diameter L popliteal aneurysm is found. What additional test and tx are indicated?
MRA/CTA
Surgery
Clinical findings of Peripheral artery aneurysm?
If femoral pulsatile mass in groin
Popliteal are often undetected. Symptoms typically ischemia-range from sudden onset pain to paralysis, to short distance claudication
Recurrent pain requires thorough workup
What imaging is the gold standard for peripheral artery aneurysm?
Duplex US
Define Raynaud’s Phenomenon?
Paroxysmal digital ischemia
MC cause of Raynauds Phenom?
Exagerated distal arteries in response to cold/stress
What part of the body does Raynaud’s Phenom typically effect?
The fingers (but can effect toes as well)
What are the 2 phases of Raynaud’s Phenom?
Initial
Recovery
Describe the initial phase of Raynaud’s Phenom?
eccessive vasoconstriction—-digital pallor or cyanosis
-Fingers turn white when exposed to cold and become painful
Describe the Recovery phase of Raynaud’s Phenom?
Vasodilation—-intense hyperemia (increased blood flow) and rubor
-intense rubor, throbbing, parastehsias, pain, and slight swelling
What are the two types of Raynaud’s Phenom?
Primary
Secondary
Describe Primary Raynaud’s Phenom?
Idiopathic (Raynaud's dz) 2-6% of adults MC in young women appears first btwn agent of 15-30 SYMMETRIC INVOLVEMENT IS THE RULE
Describe secondary Raynaud’s Phenom?
Rare
assoc. with Rheumatic disease
CAUSES DIGITAL PITTING, ULCERATION AND/OR GANGRENE
General Tx of Primary RP?
Keep extremities warm Protect from injury Smoking cessation tx dry skin Avoid sympathomimetic drugs (decongestants, diet)
Medciations tx for Primary RP?
In severe cases
CCB’s (first line)
A-adrenergic antagonists
Tx of Secondary RP?
General measures are the same as primary
Tx underlying illness (Rheumatology consult)
Define Acrocyanosis?
Arterial vasoconstriction and secondary dilation of the capillaries and venues resulting in PERSISTENT (NOT EPISODIC) CYANOSIS OF HANDS and occasionally feet
Do pain, ulcers, gangrene occur with Acrocyanosis?
NO
What will focused PE show with acrocyanosis?
Normal pulses
cyanosis
mois t palms
blanching does not occur
tx for acrocyanosis?
avoid cold exposure
Define Pernio (Chilbains)
Vasculitis d/o assoc. w/ exposure to cold
Who does Pernio MC occur in?
Young women, (may still occur in adults and children)
How does Pernio present?
raised erythematous lesions developed in distal lower extremities in cold weather
Tx for pernio?
Avoid exposure to cold
Wound care for ulcers
Sympatholytic agents and dihydropyridine CCB may be effective
