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Cardiology Exam 4 > Peripheral Artery Disease > Flashcards

Peripheral Artery Disease Flashcards

1
Q

What is Peripheral Artery Disease?

A
  • Occlusion or Stenosis of the Arteries of the Upper or Lower Extremities –AHA 2006 definition
  • Distinct from Mesenteric, Renal and Cerebral Vascular arteries
  • P.V.D. – includes arteries and veins
  • Effects 8 to 12 million Americans –12% - 20% of Americans age 65 and older –Only 25% are undergoing treatment
  • Effects males and females equally
  • There is a poor awareness even by the physicians
  • Most patients have never heard of it
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2
Q

PAD is a marker for? Severity of PAD is associated with?

A
  • Is a marker for systemic atherosclerotic dis.
  • Marker of Coronary Artery Disease & Cerebral Vascular Disease
  • Severity of P.A.D. is closely associated with risk of: –Myocardial Infarction –Ischemic C.V.A. –Death from other vascular causes
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3
Q

PAD presence increases what?

A
  • Presence of P.A.D. independently predicts increase in all-cause Mortality (3.1x) & Cardiovascular Mortality (5.9x)
  • 2,200 Americans Die of Diseases of the HEART and BLOOD VESSELS each day, more than 800,000 each year –150,000 are under 65 years of age
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4
Q

PAD presents in which three ways?

A

– Acute Ischemia
– ChronicDisease
– Acutely Ischemic episode overshadowing Chronic Disease

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5
Q

In the lower extremities PAD is characterized by which three ways?

A

– Asymptomatic
– to Intermittent Claudication
– to Pain at Rest

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6
Q

When looking at a PAD symptom patient what else could it be?

A
  • Arthropathies –D.J.D. / Osteoarthritis –Gout –Skeletal / Connective tissue disorders
  • Tendonitis
  • Achilles tendon injury
  • Muscle tear
  • Spinal or other Neuro-muscular Disorders –Caudaequina Syndrome (Pseudo-claudication)
  • Neuropathy (Diabetes)
  • Venous Disease –Deep Venous Thrombosis –Venous Insufficiency –Venous Stasis
  • Extrinsic Pressure disorders –Popliteal Artery Entrapment Syndrome –Baker’s Cyst –Tumors / Masses
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7
Q

What is the anatomy of the normal vessel wall?

A
  • Normal Vessel Wall
  • Three Layers – Intima – Medial/Muscular – Adventia
  • Vasa Vasorum
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8
Q

What is the occlusive disease that can lead to PAD?

A
  • Embolic Disease
  • Thrombotic Disease
  • Atherosclerotic –Arteriosclerosis - Generic term for a number of diseases in which the arterial wall becomes Thickened & Loses Elasticity. –Atherosclerosis
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9
Q

What is Atherosclerosis?

A
  • Greek: “Gruel”
  • Mass of Fibrous Plaque of degenerated, thickened arterial Intima
  • Extrudes into the arterial lumen
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10
Q

Cause of Atherosclerosis? Associated with? How much narrowing needs to happen before decreasing blood flow?

A
  • No Known Cause - Many contributing Factors
  • A Localized Finding of a Generalized / Systemic Process
  • Associated Leading Cause of Death from – Heart Attacks – Stroke
  • Arterial Narrowing of 20% - 25% before significant decrease in Blood Flow
  • Sub-intimal Fibrosis with Hyaline Degeneration –Weakening of Elastic Lamella of the Wall of the Vessel –May Lead to Aneurysms
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11
Q

Common sites for PAD?

A
  • Arterial Bifurcations common locations – Aortic Branches at their Take-offs – Common Carotid Artery Bifurcation – Aortic Bifurcation – Common Iliac Bifurcation – Common Femoral Bifurcation – Tibial - Peroneal Trifurcation
  • Superficial Femoral Artery at Adductor (Hunter’s) Canal: – “Fem-Pop territory”.
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12
Q

Acute PAD symptoms?

A
  • Acute sudden symptoms - Asymptomatic until: – Occlusion of vessel – Embolus from Heart or Blood Vessel – Thrombosis of a Vessel – Rupture of a Plaque – Plaque/Thrombus from an Aneurysm with embolus – or Rupture of an Aneurysm
  • Lack of Collateral Blood Flow may exacerbate the Problem
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13
Q

Chronic PAD symptoms?

A
  • Chronic – may be Asymptomatic: – Signs and Symptoms usually come on Slowly – Progress until Stenosis / Narrowing is significant
  • Multi-Level often – Aortic - Iliac – Femoral – Popliteal (Hunter’s Canal) – Tibial - Peroneal
  • Diabetic - Frequently below the Popliteal region
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14
Q

Evaluation of PAD?

A
  • Patient History
  • Physical Exam – Undressed
  • Non-invasive Testing
  • Invasive Testing
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15
Q

What to ask with history of PAD?

A
  1. Risk Factors

2. Symptoms 1. Claudication 2. Rest Pain 3. Impotence – need to ask

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16
Q

Co-morbidities with PAD?

A
  • Cardiac Symptoms (30% - C.A.D.) –Angina –Myocardial Infarction (20%) –Arrhythmias
  • Cerebral Vascular –T.I.A. / Amaurosis Fugax –C.V.A. (7%)
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17
Q

Not controllable risk factors for PAD?

A
  • Family History
  • Diabetes Mellitus
  • Hypertension
  • Hypercholesterolemia / Hyperlipidemia
  • Personality Type
  • Age (>40years?)
  • Race
  • Clotting / Bleeding Disorders
  • Male Sex
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18
Q

Controllable risk factors for PAD?

A
  • Cigarette Smoking – Vasoconstriction – Effects are cumulative & irreversible
  • Diabetes Mellitus
  • Hypertension
  • Hypercholesterolemia / Hyperlipidemia
  • Personality Type
  • Diet
  • Obesity
  • Reduced Physical Activity
  • Stress
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19
Q

An acute event can lead to?

A

• Hyperkalemia • Lactic Acidosis • Rhabdomyolysis

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20
Q

Acute symptoms ask what?

A
  • Pain –“When did it start”?
  • Loss of Sensation
  • Change of Temperature
  • Hx of P.A.D. / Previous Acute Incident
  • Symptoms of Chronic Disease prior to acute event
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21
Q

Physical exam findings for an acute PAD episode?

A
  • PAIN
  • PALLOR - Pale, Yellowish tone to the Skin
  • PULSELESS
  • PARESTHESIAS - Anoxia to Peripheral Nerves
  • PARALYSIS - Late sign, Grave Prognosis – Inability to Dorsal Flex the foot
  • COLD Extremity (Poikilothermia)
  • Collapsed Superficial Veins (Phlebo-)
22
Q

intermediate Claudication shows what from PAD?

A
  • Intermittent Claudication:
  • Muscle pain elicited by (fairly) reproducible amounts of exercise.
  • Abates upon cessation of exertion – but often recurs with more exertion.
  • It is “angina” of the legs
23
Q

Chronic symptoms of claudication?

A 
–Weakness 
–Tiredness 
–Aching
–Cramping 
–Pain 
–Numbness
24
Q

Many individuals adapt to claudication symptoms by?

A
  • Many individuals adapt to their symptoms by becoming less active; –Often not recognizing that they have done so
  • Sedentary individuals may not even experience ischemic leg symptoms
  • 5% undergo amputation within 5 years
25
Q

Questions to ask with claudication?

A

• Location? – Usually Calf or Hip – Foot if Distal Disease – Can be Hip or Lower Back

  • Ask: “How far can you walk” before pain?
  • Relief after resting?
  • Relief with continued walking?
  • Progression – Over what time frame has it developed?
26
Q

Ischemic rest pain indicates?

A
  • More Severe Disease
  • Constant Arterial Insufficiency
  • Usually Toes and Forefoot
  • “Burning Pain”
  • Worse at Night
  • Worse in Recumbent Position or Elevated – Improves with Dependency – Gravity helps
  • If Unrelieved – Imminent Tissue/Limb Loss
27
Q

Physical exam signs of chronic PAD?

A
  • Xanthomas
  • Trophic Changes – Hair Loss – Skin Thin and Scaly – Nails Thicken
  • Discoloration – Pallor
  • Ulceration
  • Gangrene
  • Muscle Atrophy
  • Limb Temperature may be Reduced
  • Pulses – Poor Quality / Absent
  • Bruits
  • Capillary Refill may be Diminished
28
Q

Which pulses are we looking for? what do we look for with them?

A 
Presence - Quality 
• Carotid 
• Radial 
• Femoral 
• Popliteal 
• Dorsalis Pedis (DP) 
• Posterior Tibial (PT)
29
Q

Which areas are we checking for bruits?

A
  • Carotid
  • Subclavian
  • Abdominal –Renal –Iliac
  • Femoral
30
Q

What are non-invasive testing measures for PAD?

A
  • Pressures – A.B.I. – Ankle Brachial Index (Ankle Arm Index)
  • Doppler – Segmental Wave Forms
  • Duplex Ultrasound – Wave forms – Images
  • Toe Pressure -Evaluates for ability to heal a foot or heal ulcer
31
Q

Explain the ankle brachial index?

A
  • ABI (aka - Ankle / Arm Index) • Ratio • Cornerstone of P.A.D. diagnostic testing – 95% sensitive – 99% specific
  • Screening evaluation - often • One of the most useful & easily administered tests in the Primary / Ambulatory Care setting (or elsewhere)
  • A Non-Invasive measure of P.A.D. severity: –A Marker of Atherosclerosis –An Independent Predictor of Mortality –Lower the A.B.I. the greater the Risk of a Cardiovascular event • Its an “Index
  • “1.0” is normal (0.90 to 1.30) • If hypo- or hyper-tensive ABI may be <1.0 • Ratio < 0.90 is considered abnormal – < 0.40 suggests Critical Leg Ischemia • Ratio > 1.30 suggests non-compressible Calcified vessel – Additional tests required to diagnose PAD
  • Doppler Blood Pressure in each arm –Brachial with hand held doppler –Record the arm with the higher reading and •only use this number for your calculation • Only use the pressure from the arm that has the highest blood pressure reading • This is independent of which leg pressure you are evaluating
  • Doppler Pressure in each Lower Extremity –Dorsalis Pedis (DP) –Posterior Tibial (PT) –Record higher reading of PT or DP • Then do the math
32
Q

non-invasive Exams for PAD should be conducted by whom?

A

• Exams should be Performed by a Registered Vascular Technologist – RVT • Should be interpreted by a Qualified Physician • Should be an Accredited Vascular Laboratory!

33
Q

indications for non-invasive testing for PAD?

A

Medical Necessity • (you must have a reason for the test) • Claudication • Rest pain

  • Peripheral Vascular Disease • Physical findings of ischemia – Coolness – Pallor – Cyanosis • Slow or Non-healing Ulcers / Sores • Gangrene / Pre-Gangrene • Diminished or Absent pulses (with other findings)
  • Aneurysm – suspected or known • Source of emboli • Pseudo-aneurysm– suspected or known • Dissections– suspected or known • Hematoma – suspected or known • Pre-operative evaluation of lower extremity prior to other surgery – Orthopedic surgery – Kidney transplant – Follow-up after vascular procedures • Arteritis • Vascular injury – Trauma – Interventions • Compression syndromes – Popliteal entrapment • Follow-up Surgical Revascularization • Follow-up Percutaneous Revascularization • Follow-up dialysis grafts / fistulas
34
Q

What is segmental pressure test?

A
  • Further localizes level of disease.

* Can classify into 4 groups: – No Disease – Aorto-Iliac Disease – Femoral-Popliteal Disease – Combined Disease

35
Q

Duplex ultrasound exam serves an important role in what areas of PAD? Identifies what?

A
  • Important Role In: –Initial Diagnosis of P.A.D. –Treatment Planning of P.A.D. –Follow-up of P.A.D. and Interventions • 95% Sensitivity • 99% Specificity
  • Identifies: – Normal Flows – Occlusion • Absence of Flow – Stenosis • Location • Quantifies degree of Stenosis • Guides Treatment of Iatrogenic problems such as Arterial Pseudoaneurysms
36
Q

CT angiography requires? Limited benefit when?

A

• C.T.A. • Commonly available • Requires contrast which has its risks –Renal toxicity –Allergic • Limited benefit if artery is heavily calcified

37
Q

MRI with angiography in PAD?

A

• M.R.A. • Major advances • Intra-arterial contrast agents –Renal toxicity –Allergic

38
Q

PAD in the lower extremities specific diseases?

A
  • Aortic Occlusive Disease –Lerich’s Disease
  • Aorto-Iliac Occlusive Disease
  • Femoral-Popliteal Disease
  • Femoral-Tibial Disease
39
Q

What is Lerich’s Syndrome?

A

• “Lerich’s Syndrome” • Gradual Occlusion at the Terminal Aorta • Bilateral symptoms • Fatigue of the Legs with Exercise • Atrophy of the Leg Muscles • Trophic Changes of the Feet • Discoloration of the Skin of the Legs • Impotence

40
Q

What is Aortic-Iliac Occlusive disease?

A

• “Inflow” Obstruction: –Aorta, Common &/or External Iliac Arteries • Collateral Vessels may provide flow into the legs • Hip, Thigh or Buttock Claudication • Impotence • Absence of Femoral Pulses or Diminished Pulses – Bruits +/

41
Q

femoral popliteal or Tibial occlusive disease?

A
  • Adductor Canal (Hunter’s Canal) –Most common location - 50%-60% of patients
  • Profunda Femoris Artery take-off –Second most common lesion –P.F.A. is important Collateral Flow when S.F.A. is occluded
  • Claudication - Calf Pain • Pain may be Reduced when the Limb is Dependent • also - Popliteal Entrapment Syndrome
42
Q

Goals of treatment for Claudication?

A

• Goals of treatment for Claudication: –Relieve Exertional symptoms –Improve Walking Capacity –Improve Quality of Life

43
Q

What are the goals of treatment for claudication is there is Critcal leg ischemia?

A

Goals if Critical Leg Ischemia: –Relief of Ischemic Pain at Rest –Healing of Ischemic Ulceration –Prevent Limb Loss

44
Q

Explain the conservative therapy of PAD? Requires?

A

• Education - Provide information on P.A.D. –Etiology –Prevention strategies –Smoking Cessation –Available therapeutics
• Modification of known Risk Factors (that can be) – Smoking!! – Hypercholesterolemia • Support those Risk Factors that cannot be… • Facilitate lifelong lifestyle changes • Prevention of known atherosclerotic complications • Medication therapy as indicated
Exercise – Progressive • Walking – Cycling, water aerobics, etc. • Can be an organized / supervised program • 30 minutes per session – Up to 45 to 60 minutes a day • Three to five times per week • To the point of near-maximal discomfort

Requires motivated patient • Improvement is probably result of Increased collateral flow and Improved muscle function • It may take weeks to months of routine exercise before improvement is appreciated • Advise patience & not to become discouraged • Advise patients that claudication is not (necessarily) a warning sign of impending disaster

45
Q

Medication therapy for PAD?

A
  • Lipid Lowering Therapy –Has benefit
  • Treatment of Diabetes Mellitus –May not directly effect PAD
  • Treatment of Hypertension
  • Aspirin - #1 medication –Reduced risk of non-fatal MI, Ischemic Stroke and Death from Vascular causes –May Favorably affect peripheral circulation –Improves Graft Patency –Low dose (75 - 325 mg / day) may be as effective as High dose (600 - 1500 mg / day
  • Clopidogrel Bisulfate (Plavix®) –Inhibitor of ADP-induced platelet aggregation –FDA approval for prevention of ischemic complications of P.A.D.
  • Cilostazol (Pletal®) • Aggrenox® (Dipyridamole / Aspirin) • Pentoxifylline (Trental®) • Dipyridamole (Persantine®) • Ticlopidine HCl (Ticlid®)
46
Q

Therapy for an Acute event?

A
  • Diagnosis –Non-invasive testing –Arteriogram (+/-)
  • Anticoagulant: –Unfractionated Heparin - acute treatment –Low Molecular Weight Heparins • Daltaparin & Enoxaparin –Thrombin Inhibitors - Fondaparinox
  • Thrombolytic Therapy –Thrombolysis • Thrombo-Embolectomy
47
Q

When do you consider vascular reconstruction?

A

When Do You Consider Intervention? • Unable to perform normal daily activities • Failure of Conservative Treatment • Incapacitating - Claudication • Rest Pain • Tissue Compromise / Loss • Threatened Limb Viability • Life Threatening

48
Q

what are some of the endovascular treatments?

A
  • Percutaneous Transluminal Angioplasty / Stent (PTA) – Iliac Arteries - 80%-90% Patency rate at 5 years
  • Atherectomy - De-bulk the lesion • Laser Angioplasty - Making a Resurgence
49
Q

Aorto-iliac surgeries?

A
  • Aorto-Bi-Femoral –Abdominal and Femoral (groin) Incisions
  • Aorto-Bi-Iliac Bypass –Abdominal Incision

Femoral - Femoral Crossover Bypass • Bilateral Femoral (groin) Incisions • Can be Performed Under Local Anesthetic if Necessary

50
Q

Femoral popliteal bypass?

A
  • ‘Historically’ the Most Common form of Open Surgical Revascularization for the lower extremity
  • 30% - 50% occlusion rate at five years
  • Much less common now with increased use of percutaneous approach
  • Above Knee – Polytetrafluoroethylene(PTFE - Gortex®) – Dacron – Autologous Saphenous Vein • In-situ vs R.S.V.G.
  • Below Knee – Autologous Vein – Best Choice
51
Q

PAD is a marker of? Patients with symptomatic extremity percent chance of PAD? patients with symptomatic CAD percent chance of PAD?

A
  • Marker of CAD & CVD
  • The association between cardiac and peripheral arterial disease is well established
  • Patients with symptomatic extremity PAD – 75% will have CAD
  • Patients with symptomatic CAD – 25% will have PAD

Cardiology Exam 4 (21 decks)

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