Peripheral Artery Disease - PVD Flashcards
What are the risk factors?
- CAD/artheroscleorisis
- advanced age
- hypercholesterolemia
- smoking
- hypertension
- diabetes
- overweight
- family hx
What are the characteristics of patients with increasd risk of PAD?
- 65 years and over
- 50-64 with risk factors of artherosclerosis or family hx of PAD
- under 50 with DM and 1 risk factor for atherosclerosis
- with known atherosclerotic disease
- AAA - abdominal aortic aneurysm
Pathohysiology
What is the assumed cause?
mismatch of demands of the body’s organs and muscles with supply of O2
- this is because of atherosclerotic stenosis of peripheral arteries
reduced diameter of blood vessels = ischemia
Pathophsysiology
What occurs during exercise?
metabolism makes adenoside -> dilation of arterioles = increase blood flow to muscles
Pathophysiology
What is another factor that leads to ischemia?
obstructed arteries which can’t act well to vasodilation stimulus and blood flow
- dramatic reduction to exercise tolerance
Pathophysiology
Local adaptations to chronic ischemia will lead to changes in what?
Muscle fiber metabolism and skeletal muslce degeneration
Pathophysiology
What can lead to lower extremity weakness?
Physical and biomechanical changes
Pathophysiology
What does ischemic changes in multiple arteries lead to?
ischemic sx at rest (very similar to angina)
Clinical Presentation
What are the vessels most commonly affected?
- aorta
- iliac femoral
- popliteal
- tibialperoneal arteries
Clinical presentation
What vessels are affected if there is arm pain?
brachiocephalic or subclavian
Clinical Presentation
Where is intermittent claudication affected?
- buttock
- hip
- thigh
- calf pain
- sometimes feet and toes
Clinical presentation
What is the prevalence of intermitted claudication?
- only about 1/3 experience it
- about 1/3 experience atypical sx
- about 1/3 are asx
Clinical presentation
What are the atypical sx?
leg pain/carry on - able to keep exercising through the pain or pain that starts at rest w/o critical limb ischemia
Clinical Presentation
Where is the location of sx?
Distal to the stenotic artery
Chronic Presentation
Chronic ischemia leads to?
Ulceration, infection and skin necrosis
Clinical Presentation
What are the clinical presentation?
- dimished or absent pulses distal to stenosis
- muscle atrophy
- pallor or reduced temp when elevated (rubor of dependency)
- shiny, taut skin - typically with hair loss and brittle, thick, dry toenails (trophic changes)
- wounds
- gangrene
- necrosis of foot and digits
- reduced sensation
- associated with diabetes
ACSM Intermittent Claudication Scale
Grade 1
Definite discomfort or pain
- but only initial or modest levels
ACSM Intermittent Claudication Scale
Grade 2
Mod discomfort or pain from which the patient attention can be diverted
ACSM Intermittent Claudication Scale
Grade 3
Intense pain from which the patient’s attention can’t be diverted
ACSM Intermittent Claudication Scale
Grade 4
Excuciating and unbearble pain
Ankle Brachial Index
What is considered normal measurement?
greater than 1.10
Ankle Brachial Index
0.5 - 1.0
sx: claudications
clinical presentation: pain in calf with ambulation
Ankle Brachial Index
0.2-0.5
sx: critical limb ischemia
clinical presentation: atrophic changes, pain at rest, wounds
Ankle Brachial Index
less than 0.2
sx: severe ischemia
clinical presentation: gangrene, severe necrosis
What is critical limb ischemia?
Progression of PAD
- circulation can’t meet resting metabolic demands
- in early stages - collateral circulation will compensate
Critical Limb Ischemia
1st critical phase
When collateral circulation can’t meet the needs of metabolic demand
- limited blood supply will affect muscles and skin = wound will be compromised
Critical Limb Ischemia
2nd critical phase
Pain is experienced with exercise
- increasing muscle O2 demand
Critical Limb Ischemia
3rd critical phase
Seen with resting pain
- non-healing wounds
- risk to infections
- risk for gangrene
What is acute cold leg?
When there is an acute arterial occlusion
- a vascular emergency = longer delay will lead to amputation
Acute Cold Leg
What is the cause of acute cold leg?
in situ thrombic occlusion - most often in femoral artery or embolism
Acute Cold Leg
What are the sx?
sudden onset of:
- cold
- pale
- pulseless
- painful
- parasthetic
- paralytic leg
Acute Cold Leg
How is it treated medically?
with revascularization
Acute Cold Leg
What is the indication for an amputation?
- mottled
- non-blanching with hardened, woody muscle
Clinical Categories of Acute Limb Ischemia
What is the prognosis of IIA (marginally threatened)?
salvageable
- if promptly treated
Clinical Categories of Acute Limb Ischemia
IIA - sensory loss
minimal (at toes) or none
Clinical Categories of Acute Limb Ischemia
IIA - possible doppler
arterial - inaudible
venous - audible
Clinical Categories of Acute Limb Ischemia
IIB (immediately threatened) - prognosis
salvageable if immediately revascularized
Clinical Categories of Acute Limb Ischemia
IIB - prognosis
Salvageable if immediately revascularized
Clinical Categories of Acute Limb Ischemia
IIB - sensory loss
more than toes, pain at rest
Clinical Categories of Acute Limb Ischemia
IIB - motor deficit
mild to moderate
Clinical Categories of Acute Limb Ischemia
IIB - possible dobler
arterial - inaudible
venous - audible
Clinical Categories of Acute Limb Ischemia
III (irreversible) - prognosis
Major tissue loss
permanent nerve damage
nerve damage inevitable
Clinical Categories of Acute Limb Ischemia
III - sensory loss
profound loss
Clinical Categories of Acute Limb Ischemia
III - motor deficits
profound, paralysis
Clinical Categories of Acute Limb Ischemia
III - possible dopplers
both inaudible dopplers for arterial and venous
ACSM Guidelines
What is the guideline for aerobic activity?
3-5x per week @ RPE 12-16 for 20-60 min per session
- walking speed should be at a pace to elicit caludations in 3-5 mins
ACSM Guidelines
What is the guideline for resistance activity?
2x per week
- focusing on larger muscle
- emphasis on lower limbs
ACSM Guidelines
What is the guidelines for flexibility?
2-3x per week
What are the surgical interventions for PAD?
- angioplasty with/or without stent
- bypass surgery
- femoral popliteal bypass
When is exercise resumed after an angioplasty?
generally improved right away and helps with healing of distal wounds
- exercise can resume 72 hrs post
When is exercise resumed after bypass surgery?
sx should resolve and out of bed after 1 day
- encourage activity once the wounds heal
- limit lifting for 6 weeks
When is exercise resumed after femoral-popliteal bypass surgery?
used for critical limb ischemia
- OOB walking after day 1 post op
- go back to activity once wounds heal
- monitor limb tthrough healing
