Peripheral Artery Disease

Question 1

ABI (ankle brachial index) equation

Answer 1

SBP of doralis pedis or posterior tibial artery / SBP of brachial artery

Question 2

normal ABI

Answer 2

0.91-1.3

Question 3

ABI >1.3

Answer 3

suggestive of calcified or uncompressible vessels seen in DM2 or CKD, needs additional vascular studies

Question 4

ABI <0.9

Answer 4

diagnostic of PAD

Question 5

If ABI are non diagnostic what study do you order?

Answer 5

toe-brachial index, pulse volume recordings, arterial duplex ultrasound

or get exercise ABIs

Question 6

what is neurogenic claudication?

Answer 6

lumbar spinal stenosis Causes bilateral or asymmetrical lower extremity pain weakness or sensory loss that is exacerbated by walking or prolonged standing in erect postures,

Question 7

What makes neurogenic claudication better?

Answer 7

sitting or assuming a stooped or flexed posture

Question 8

Presentation of neurogenic claudication

Answer 8

bilateral or asymmetrical lower extremity pain weakness or sensory loss that is exacerbated by walking or prolonged standing in erect postures,

Question 9

What is venous claudication?

Answer 9

lower extremity discomfort in pts with chronic venous dx. Symptoms are worse in prolonged dependent position.

Question 10

modifying risk factors include:

Answer 10

stopping smoking graded exercise therapy to improve symptoms and decrease progression of dx

Question 11

initial therapy for PAD

Answer 11

antiplatelet with aspirin (due to cost and efficacy). Clopidogrel can be used in pts who cannot tolerate aspirin. PTs who are symptomatic on antiplatelet need second line agents like cilostazol or a phospohdiesterase inhibitor and vasodilator that inhibits platelet aggregation and increases maximal and pain free walking distances.

Question 12

cilostazol

Answer 12

second line drug, use after antiplatelet. DIrect arterial vasodilator and inhibitor of platelet aggregation. improves pain free walking distance and symptoms, mainly for patients who don’t meet criteria for revascularization

Question 13

when is cilostazol contraindicated?

Answer 13

in pts with heart failure

Question 14

pentoxifylline

Answer 14

this improves symptoms of claudication increases red blood cell deformity and improves circulation has limited benefit and is second line therapy for symptom relief. trials on efficacy are inconsistent about improving walking capacity

Question 15

what is criteria for revascularization?

Answer 15

ABI >0.5 or failed medical or exercise therapy or unable to do ADLs. otherwise if not there yet, use cilostazol

Question 16

when do we revascularize someone - surgically or percutaneously?

Answer 16

if someone who fails all exercise and medical therapy, who have significant disabling claudication preventing ADLs or limb threatening ischemia ABI usually 0.5

Question 17

Algorithm for PAD

Answer 17

Question 18

Clinical features of PAD

Answer 18

See below

Question 19

Leriche’s syndrome is

Answer 19

triad of claudication, diminished femoral pulses, and ED

This resutls in severe aortoiliac occlusive PAD

Question 20

localized hip or buttock pain, diminished femoral pulses and claudication. Hear bruits over the femoral or iliac arteries and cool extremities and prolonged venous fillign time and skin and muscle atrophy and prolonged wound healing and foot pallor

Answer 20

severe aortoiliac dx with PAD.

Question 21

in those pts who have symptoms of intermitten claudication, erectile dysfunction, toe ulceration and NORMAL ABI what do you do?

Answer 21

get exercise testing then repeat ABI as this will help provoke dx

if normal ABI after exercise this excludes occlusive PAD.

ABI that decreases by >20% following exercise is diagnostic of occlusive PAD.

Question 22

Risk factors for PAD?

Answer 22

male gender

known CAD

advancing age

DM2

HTN

HLD

black race

hyperhomocysteinemia

Question 23

physical exam of PAD?

Answer 23

diminished pulses, decreased hair, skin pallor, arterial ulcers

Lab testing is normal

ABI <0.9 is diagnostic

ABI can be normal but if still suspect PAD get exercise ABIs

Question 24

are CT angiography, MR angiography and duplex imaging helpful for PAD diagnosis?

Answer 24

no it’s meant for surgical planning after diagnosis is established and needs revascularization.