Peripheral Artery Disease

Question 1

Peripheral Artery Disease

Answer 1

Characterized by STENOSIS or OCCLUSION in the AORTA or ARTERIES of the LIMBS

Question 2

The leading cause of PAD in patients > 40 y/o

Answer 2

Atherosclerosis

Question 3

CARDINAL symptoms of PAD

Answer 3

intermittent claudication and pain at rest

Question 4

Occurs when the oxygen demand of skeletal muscle during effort exceeds the blood’s oxygen supply

Answer 4

intermittent claudication - pain, ache, cramp, numbness or sense of fatigue in the muscles which occurs during exercise and is relieved by rest

Question 5

Pathophysiologic Considerations in PAD

Answer 5

FACTORS REGULATING BLOOD SUPPLY TO LIMB

Flow-limiting lesion (stenosis severity, inadequate collateral vessels)

Impaired vasodilation (↓ NO, ↓ responsiveness to vasodilators)

Accentuated vasoconstriction (thromboxane, serotonin, angiotensin II, endothelin, norepinephrine)

Abnormal rheology (↓ RBC deformability, increased leukocyte adhesiveness, platelet aggregation, microthrombosis, ↑ fibrinogen

ALTERED SKELETAL MUSCLE STRUCTURE AND FUNCTION

Axonal degeneration of skeletal muscle

Loss of type II, glycolytic fast-twitch fibers – ↓ muscle strength and reduced exercise capacity

Impaired mitochondrial enzymatic activity

Question 6

Buttock, hip, thigh, and calf discomfort

Answer 6

Aortoiliac Disease

Question 7

Calf claudication

Answer 7

Femoral-Popliteal Disease

Question 8

Ankle or foot claudication

Answer 8

Tibial and Peroneal Disease

Question 9

Consumes more oxygen during walking than other muscle groups in the leg do and causes the most frequent symptoms reported by patients with PAD

Answer 9

Gastrocnemius

Question 10

Developed initially to DIAGNOSE BOTH ANGINA and INTERMITTENT CLAUDICATION in epidemiologic surveys

Answer 10

Rose Questionnaire

Question 11

Normal right femoral pulse but absent left femoral pulse

Answer 11

(+) Left Iliofemoral Arterial Stenosis

Question 12

Normal femoral artery pulse but absent popliteal artery pulse

Answer 12

Stenosis in the Superficial Femoral Artery or Proximal Popliteal Artery

Question 13

Sign of accelerated blood flow velocity and flow disturbance at sites of stenosis

Answer 13

Bruits

Question 14

PE in PAD

Answer 14

decreased or absent pulses distal to obstruction

bruits over narrowed artery

muscle atrophy, hair loss, thickened nails, smooth and shiny skin

reduced skin temp, pallor, cyanosis, ulcers and gangrene

Question 15

Fontaine Classification of PAD

Answer 15

Stage

I - asymptomatic

II - intermittent claudication
IIa - pain free, claudication walking > 200 m
IIb - pain free, claudication walking < 200 m

III - rest and nocturnal pain

IV - necrosis and gangrene

Question 16

Rutherford Classification of PAD

Answer 16

Grade and Category

1 , O - asymptomatic

II - 1 - mild claudication
II - 2 - moderate claudication
II - 3 - severe claudication

III - 4 - ischemic rest pain
III - 5 - minor tissue loss, nonhealing ulcer, focal gangrene w/ diffuse pedal ulcer
III - 6 – major tissue loss extending above the transmetatarsal level, functional foot no longer salvageable

Question 17

Ratio of SYSTOLIC BLOOD PRESSURE measured at the ANKLE to SYSTOLIC BLOOD PRESSURE measured at the BRACHIAL ARTERY

Answer 17

Ankle Brachial Index

Question 18

Interpretation of Ankle-Brachial Index

Answer 18

1. 0-1.4 – NORMAL
2. 91-0.99 – BORDERLINE

PAD - <0.90
leg claudication – 0.5-0.8
critical limb ischemia – 0.3-0.5
gangrene - <0.3

Question 19

Used to IMAGE AND DETECT STENOTIC LESIONS in arteries and bypass grafts

Answer 19

Duplex ultrasonography

Question 20

Evaluate the clinical significance of PERIPHERAL ARTERY STENOSES and provide objective evidence of the patient’s walking capacity

Answer 20

Exercise Treadmill ABI

Question 21

One of the simplest and most useful noninvasive measures for ascertaining the presence and severity of stenoses in the peripheral arteries

Answer 21

Segmental Pressure Measurements

Question 22

Ankle pressures <50 mmHg or toe pressures <30 mmHg

Answer 22

Critical Limb Ischemia

Question 23

Noninvasively visualize aorta and peripheral arteries

Answer 23

Magnetic Resonance Angiography

Question 24

Aids in evaluation of the ARTERIAL ANATOMY BEFORE A REVASCULARIZATION PROCEDURE

Answer 24

Contrast-Enhanced Angiography

Question 25

INHIBITS THROMBOXANE A2 SYNTHESIS by acetylation of a serine residue on the active site of COX-1

Answer 25

Aspirin

Question 26

Inhibits the binding of ADP to its receptors by INHIBITING ACTIVATION OF GP IIB/IIA RECEPTORS required for platelets to bind fibrinogen to each other

Answer 26

Clopidogrel

Question 27

REDUCE THE RISK OF CARDIOVASCULAR EVENTS in px with symptomatic PAD

Answer 27

ACE-I or ARBs

Question 28

Treatment of HYPERCHOLESTEROLEMIA and advocated to REDUCE THE RISK OF MYOCARDIAL INFARCTION, STROKE, AND DEATH

Answer 28

Statins

indicated for all patients w/ PAD

Question 29

HMG CoA reductase inhibitor that ↓ LDL

Answer 29

Statins

Question 30

Platelet inhibitors recommended for patients with SYMPTOMATIC PAD, including those with intermittent claudication or critical limb ischemia or prior lower extremity revascularization

Answer 30

Aspirin and Clopidogrel

Question 31

Protease activated receptor-1 antagonist that inhibits thrombin-mediated platelet activation, ↓ the risk of adverse cardiovascular events in atherosclerosis including PAD and ↓ the risk of acute limb ischemia and peripheral revascularization

Answer 31

Vorapaxar

Question 32

Oral factor Xa inhibitor

Answer 32

Rivaroxiban

Question 33

Quinolone derivative that INHIBITS PHOSPHODIESTERASE III with vasodilator and antiplatelet derivatives which increases claudication distance by 40-60%

Answer 33

Cilostazol

increases walking distance in patients w/ claudification

C.I
CHF

Question 34

Substituted XANTHINE DERIVATIVE which ↑ blood flow to the microcirculation and enhances tissue oxygenation

Answer 34

Pentoxifylline