Peripheral Artery Disease Flashcards
What carotid artery stenosis?
Stenosis of the internal carotid artery
Is the ischemia in carotid artery stenosis reversible?
Yes
What may happen with reperfusion after ischemia?
Additional emboli or stroke
What are most ischemic strokes due to?
Emboli from the heart
Symptoms of ischemic cerebrovascular disease are predominantly due to what?
Emboli
Which artery do emboli typically arise from?
Proximal internal carotid artery
What artery is particularly prone to atherosclerosis?
Proximal internal carotid artery
What are symptoms of carotid artery stenosis?
Amaurosis fugax
Transient ischemic attacks
Ischemic stroke on the same side as lesion
What determines how carotid artery stenosis is treated by carotid endarterectomy?
Patient’s risk for TIA or stroke
What are risk factors for carotid artery stenosis?
HTN Heart disease Smoking Older age Male sex Hypercholesterolemia DM
What are the two categories of carotid artery stenosis?
Asymptomatic
Symptomatic
What are indications for a carotid ultrasound?
Cervical bruit
What is the sensitivity and specificity for detection of > 70% stenosis with carotid duplex ultrasonography?
Sensitivity: 90%
Specificity: 94%
Does screening for bruit on physical exam have good reliability and sensitivity?
No
What does the aorta of a healthy young man measure?
2cm
When is an aortic aneurysm considered present?
Greater than 3cm
What percent of abdominal aortic aneurysms originate below the renal arteries?
90%
Which arteries are involved in abdominal aortic aneurysm?
Aortic bifurcation
Common iliac arteries
What are aortic aneurysms most often associated with?
Atherosclerosis
What is aortic dissection most often associated with?
HTN
What are inflammatory aneurysms?
Have inflammatory peel
Surrounds the aneurysm and encases adjacent retroperitoneal structures such as the duodenum and the ureters
What are clinical findings seen with ruptured aneurysms?
Severe pain
Palpable abdominal mass
Hypotension
Free rupture into the peritoneal cavity is lethal
Most aneurysms have a thick layer of thrombus lining the aneurysmal sac
Is embolization in the lower extremities seen with aortic aneurysms?
No
Is hematocrit normal in abdominal aneurysms?
Yes
What other disease are concomitant with abdominal aneurysm?
Coronary artery disease
Carotid disease
Kidney impairment
Emphysema
What is the diagnostic study of choice for initial screening for abdominal aneurysm?
Abdominal ultrasonography
Who is abdominal ultrasonography good for screening abdominal aneurysms?
65-75 year old men
Who is abdominal ultrasonography bad for screening abdominal aneurysms in?
Women with a history of smoking
What is seen on abdominal or back radiographs with abdominal aneurysms?
Curvilinear calcifications outlining portions of aneurysm wall
When is emergency repair possible in aortic aneurysms?
Blood in contained to the retroperitoneum
Is surgery indicated in inflammatory aneurysms?
No (unless retroperitoneal structures are compressed)
Where is the graft sutured in abdominal aneurysms?
Above aneurysm and below aneurysm
How is endovascular repair done in abdominal aneurysms?
Line the aorta and exclude the aneurysm
Which type of abdominal aneurysm needs additional interventions?
Endovascular repair
When should a CT scan be ordered for abdominal aneurysm?
When near 5.5cm for treatment
What is the most common peripheral artery occluded by atherosclerosis?
Superficial femoral artery
What ethnicities are most impacted by superficial femoral artery atherosclerosis?
Blacks
Hispanics
What arteries are also sometimes occluded and result in short-distance claudication?
Common femoral artery
Popliteal artery
What intermittent claudication symptoms in the common femoral, superficial femoral, and popliteal artery are confined to what?
Calf
When does claudication happen?
Occurs at 2-4 blocks when there is occlusion or stenosis of the superficial femoral artery provided there are good collaterals
What is seen with short-distance claudication?
Dependent rubor of the foot with blanching on elevation
What does chronic low blood flow states cause?
Atrophic changes in the lower leg and foot with loss of hair
Thinning of the skin and cutaneous tissues
Disuse atrophy of the muscles
What is seen with segmental occlusive disease of the femoral artery?
Common femoral pulsation normal
Popliteal and pedal pulses are reduced
Where does claudication typically occur?
Legs during exercise and disappears with rest
What is peripheral artery disease associated with?
Increased mortality Limited exercise tolerance Chronic ischemic ulcers Susceptibility to infection Need amputation
Is ankle-bachial indices recommended for asymptomatic patients?
No
Ankle-brachial indices predicts what more accurately than is possible using history and PE alone?
Angiography results
What is the ABI cutoff for patients with suspected PAD?
<0.9
How do you calculate right ABI?
Higher right ankle pressure/Higher arm pressure (right or left)
How do you calculate left ABI?
High left ankle pressure/Higher arm pressure (right or left)
What do ABI levels below 0.4 suggest?
Chronic limb-threatening ischemia
What do ABI readings depend on?
Arterial compression
When can ABIs be misleading?
Calcification due to DM, CKD, older adults
What is used instead of ABI in special patients?
Toe-brachial index (0.7 diagnose PAD)
What imaging is done for PAD if revascularization is planned?
Duplex ultrasonography
CT angiography
MR angiography
What is the medical and exercise therapy for PAD?
High-dose statin
Exercise treatment
What is the surgical treatment for PAD indicated?
Claudication is progressive, incapaciting, or interferes with daily life
When is surgical treatment for PAD mandatory?
Ischemic rest pain or ischemic ulcers threaten the foot
When is bypass surgery done?
Lesions of the superficial femoral artery done with femoral-popliteal bypass with autologous saphenous vein
When is endovascular surgery done?
Angioplasty/stenting of superficial femoral artery
Does endovascular have a lower morbidity than bypass?
Yes
Does endovascular surgery last longer than bypass surgery?
No
What is thromboendarterectomy?
Removal of arterosclerotic plaque is limited to the lesions of the common femoral and profunda femoris arteries
What antiplatelet drugs are used in PAD?
Aspirin
Clopidogrel
What do aspirin and clopidogrel do for PAD?
Reduce risk of MI, stroke, and vascular death
What two drugs are used exclusively for PAD?
Cilostazol
Pentoxifylline
What is cilostazol?
PDE3 inhibitor
Increases exercise tolerance in patients with severe claudication
What is Petoxifylline?
Xanthine derivative
NOT RECOMMENDED
What are the risk factors for PAD?
Age less than 50 with DM (smoking, dyslipidemia, HTN, homocysteinemia)
Age 50-69 with hx of smoking or DM
Age > 65
Abnormal lower extremity pulses
Leg symptoms with exertion or ischemic rest pain
Known coronary, carotid, or renal atherosclerosis
What is the leading cause of lower extremity wounds and amputations?
PAD
What are the screening tips for PAD?
Patient has risk factors for PAD (thus CVD) or symptoms of claudication suggestive of PAD
Screen with ABI
If negative, still suspicion for PAD
Perform exercise stress test with post-exercise ABI
What is a severe manifestation of venous HTN?
Chronic venous insufficiency
What is a complicating factor of venous lower extremity disease?
Obesity
What is a common cause of venous lower extremity disease?
Progressive superficial venous reflux
What is seen in lower extremity disease (venous)?
Edema
Skin pigmentation
Subcutaneous lipodermosclerosis in lower leg
Large ulceration at/above medial ankle (venous ulcer)
Patients often have a history of what in chronic venous insufficiency?
DVT Leg injury (trauma or surgery)
Stasis dermatitis is common in what?
Chronic venous insufficiency
What is the yellow color seen in chronic venous insufficiency?
Lipodermosclerosis
What is the dark color seen in chronic venous insufficiency?
Hermosiderin deposition as fluid leaks into the tissues and when it leaves it leaves heme pigments behind
What are the clinical findings with chronic venous insufficiency?
Progressive pitting edema
Subcutaneous changes
Itching
Dull discomfort (worse with standing)
Pain with ulceration
Skin at ankle is taut from swelling, shiny, brown pigment
SubQ tissues become thick and fibrous
Ulcerations occur at or above ankle medial/anterior
Healing results in thin scar on a fibrotic base that breaks down with minor trauma
Varicosities appear
Cellulitis
How is cellulitis diagnosed?
Blanching erythema with pain
Patients with post-thombotic syndrome or signs of chronic venous insufficiency should undergo what?
Duplex ultrasonography to determine whether superficial reflux is present and to evaluate the degree of deep reflux and obstruction
What is the most common scenario in chronic venous insufficiency?
Elderly female with CVI
Conservative treatment of compression stockings, rest with leg elevation did not help
Next step is duplex ultrasonography to look for venous reflux to determine extent of disease and determine further treatment options
What are the general treatments for chronic venous insufficiency?
Compression stockings
Avoid long periods of sitting or standing
Pneumatic compression of leg (refractory cases)
Treatment of superficial vein reflex (varicose veins) has been shown to decrease the recurrence rate of what?
Venous ulcers
When should varicose veins not be removed?
Obstruction of femoral and popliteal deep venous system
What should be used to treat chronic iliac deep vein stenosis to improve venous ulcer healing and reduce the ulcer recurrence rate in severe cases?
Venous stents
