Peripheral artery disease [PAD aka PVD] (Complete) Flashcards
Define peripheral artery disease.
Peripheral arterial disease (PAD) includes a range of arterial syndromes that are caused by atherosclerotic obstruction of the lower-extremity arteries
The incidence of PAD increases in incidence with age starting form which age?
40 onwards
List examples of risk factors for PAD. (8)
Non-modifiable:
Age > 40
Modifiable
Smoking
Diabetes
Hyperlipidaemia
Hypertension
Coronary artery disease (CAD)
Cereberovascular disease (CVD)
Low levels of exercise
What are some of the main signs/symptoms of patients with PAD? (4)
Symptoms:
Intermittent claudication
Thigh or buttock pain with walking that is relieved at rest
Erectile dysfunction
Signs:
Diminished or absent pulse (foot)
Pale, cold, legs
N.B. PAD can also be assymptomatic
What is a severe form of peripheral artery disease?
Critical limb ischaemia
List some of the presentations of critical limb ischaemia (9)
Pain in legs at rest (worse especially when supine aka on back)
Gangrene (e.g. toes and heels)
Non-healing wound/ulcer
Unilateral muscle atrophy of a lower limb extremity
Dependant rubor (foot is reddened when not elevated)
Pallor upon leg elevation
Thickened toenails
Loss of hair on the dorsum of the foot
Shiny scaly skin
What is the 1st line investigation for patients suspected of having peripheral artery disease?
Ankle Brachial Index (ABI)/ ABPI (Anchle brachial pressure index)
Compares blood pressure between the legs and arms
What investigations should be performed in patients suspected of PAD?
Any patient suspected should have a full cardiovascular risk assessment including:
Bedside:
BP: Identify hypertension risk factor
ECG: identify risk factors
Bloods:
FBC
Lipid profile: Identify risk factors
Blood glucose: Identify risk factors
Imaging/Other:
Ankle brachial pressure index (ABPI) [First-line]
What ABI score is indicative of peripheral artery disease?
ABI ≤0.90
ankle-brachial index findings are less accurate in which 2 groups of patients?
Patients with non-compressible arteries such as:
Diabetic mellitus
Renal patients on dialysis
N.B. Therefore must still suspect in these patients even if the findings appear normal.
N.B. Especially suspect if ABPI >1.2 as it suggests calcification
What investigation should be considered alongside ABI in patients with non-compressible arteries? (e.g. diabetes mellitus or renal dialysis patients).
TBI (Toe-brachial index)
TBI <0.6
Imaging:
Duplex arterial ultrasound: For those who might be suitable for revascularisation
CTA/MRA: for candidates suitable for revascularisation
What is the management plan for patients diagnosed with peripheral artery disease?
Main aim is heavy management of risk factors and co-morbidities.
Lifestyle management:
Smoking cessation: Major risk factor
Exercise training programme
Pharmacological:
Antiplatelet therapy: Clopidogrel
Statins: (e.g. artorvastatin)
Management of hypertension/diabetes co-morbidities if present: E.g. ACE, Metformin.
Naftidrofuryl oxalate: Vasodilator which can alleviate pain in peripheral vascular disease.Only given to patients in which exercise training ineffective or cannot undergoe surgery.
Surgical: For critical limb ischaemia:
Endovascular revascularisation (EVR)
Surgical revascularisation
What is the management plan for PAD patients presenting with claudication? (3)
Antiplatelet therapy (e.g. aspirin or clopidogrel)
Exercise
Risk factor modification
All patients diagnosed with PAD should be taking which medications? (2)
Statins (e.g. atorvastatin)
Antiplatelet therapy: 70mg clopidogel [Aspirin = 2nd line]
Name the medication that can be given for pain relief in patients with PAD? This medication should only be given if?
Naftidrofuryl oxalate: Vasodilator
Only given for patients with poor QoL e.g:
Exercise training ineffective
Cannot undergoe surgery
What should be managed in all PAD patients regardless of their presentation?
Aggresive management of risk factors such as:
BP
Lipids
HbA1c in diabetic patients
Smoking cessation
Dietary changes and exercise to reduce cardiovascular risks
What is the 1st line management plan for patients with acute limb ischaemia? (5)
Urgent assesment for revascularisation or amputation
Antiplatelet therapy (e.g. aspirin or clopidogrel)
Analgesia
Anticoagulation
Continued risk factor modification
What additional treatments should be considered in patients with PAD and claudication that is lifestyle limitting? (2)
Symptom relief (e.g. Cliostazol, Naftidrofuryl)
Referal to a vascular specialist to assess for revascularisation
Assesment for revascularisation should always be 1st line for which types of PAD patients?
Patients with critical limb ischaemia
List 4 complications that can arise in patients with peripheral artery disease.
Leg/Foot ulcers
Gangrene
Permament limb weakness/numbness
Permament limb pain
List 6 differentials to consider with patients suspected of having peripheral artery disease.
Spinal stenosis
Arthritis
Venous claudication
Chronic compartment syndrome
Symptomatic Baker’s cyst
Nerve root compression
What signs/symptoms and investigation findings are more suggestive of symptomatic Baker’s cyst vs peripheral artery disease?
Patients more likely to complain of pain in the calf and behind the knee.
The area around the knee may be swollen, sore, and tender.
The pain is present at rest and worse with exercise.
Ankle brachial index (ABI) will be normal and exercise ABI will show no decrease in post-exercise ABI.
No significant disease seen with arterial imaging tests.
Duplex ultrasound of the leg: cystic mass in the posterior-medial popliteal fossa.
What signs/symptoms and investigation findings are more suggestive of spinal stenosis vs peripheral artery disease? (6)
Have a history of back, buttock, hip, thigh, leg pain.
Pain has a dermatomal distribution and may experience motor weakness.
The pain may occur on standing alone and may be relieved on positional change.
ABI normal
Arterial disease imaging tends to be normal
May show degenerative changes on X-ray or MRI spine may show compression
What signs/symptoms and investigation findings are more suggestive of arthritis vs peripheral artery disease?
Pain more likely to occur at rest and/or exercise vs PAD and is not quickly relieved.
No significant disease on arterial imaging tests or ABI
X-ray of affected joint: new bone formation (osteophytes), joint space narrowing, and subchondral sclerosis and cysts.
