Peripheral Vascular Disease

Question 1

What is the normal diameter of the aorta?

Answer 1

1.8 - 2 cm

Question 2

Define aneurysm

Answer 2

Any vessel that is >50% larger than normal

Example: An abdominal aorta diameter of >3 cm (normal around 2 cm)

Question 3

What demographics are higher risk for AAA?

Answer 3

Elderly

Men

Smoker

Question 4

Where are the majority of AAAs found?

Answer 4

Infrarenal (below renal arteries)

Question 5

What is the pathogenesis of most AAAs?

Answer 5

Atherosclerosis

Thoracic/suprarenal: Marfans, Ehlers-danlos, syphilis

Question 6

What is the mortality of AAA rupture?

Answer 6

Overall 80%

60% die before arrival

Only 50% of those who arrived alive survive

Question 7

What is the USPSTF guideline for AAA screening?

Answer 7

Screen 1 time for abdominal aortic aneurysm with ultrasound in men aged 65-75 years who have ever smoked (100 cigarettes in lifetime)

Question 8

Should non-smokers or women be routinely screened for AAA?

Answer 8

Grade C- selective offering to men 65-75 who have never smoked

Grade I- too little evidence for or against screening women who have ever smoked

Grade D- DO NOT screen women who have never smoked

Question 9

Does Medicare part B cover one time AAA screening?

Answer 9

Yes for men aged 65-75 who have ever smoked or for anyone with a 1st degree relative with AAA

Question 10

At what size of AAA should the patient be referred for surgery?

Answer 10

5 - 5.5 cm

Question 11

Your patient is found to have an AAA of 3 - 3.9 cm. What is the recommended surveillance interval?

Answer 11

36 months

Question 12

Your patient is found to have an AAA of 4 - 4.9 cm. What is the recommended surveillance interval?

Answer 12

12 months

Question 13

Your patient is found to have an AAA of 5 - 5.4. What is the recommended surveillance interval?

Answer 13

6 months

Question 14

What are the highest risk demographics for aortic dissection?

Answer 14

40 - 80 years old

Males > females

Question 15

What is the most common cause of aortic dissection?

Answer 15

HTN

(prior cardiac surgery, marfans, cocaine, peri/post partum

Question 16

Compare and contrast AAA and aortic dissection

Answer 16

AAA- all 3 layers of the vessel dilate together (1 larger lumen)

AD- An intimal flap forms creating a second lumen

Question 17

What is type A v. Type B aortic dissection?

Answer 17

A- Ascending aorta

B- Descending aorta (after subclavian artery)

Question 18

Most common symptoms at presentation for type A v. Type B aortic dissection?

Answer 18

A- anterior chest pain, tearing/ripping pain

B- Back pain, tearing/ripping sensation, HTN more common

Question 19

What is the best imaging modality for aortic dissection?

Answer 19

CT angiogram

Others: TTE/TEE, MRI, aortography

Question 20

What are the treatment goals of aortic dissection?

Answer 20

Lower BP (SBP 90-100)

Lower velocity of LV ejection

IV esmolol, nitroprusside

Question 21

Define claudication

Answer 21

Reproducible ischemic muscle pain

Occurs with exercise, relieved with rest

Stable angina of the legs

Question 22

In relation to an occlusion, where do claudication typically symptoms present?

Answer 22

Symptoms are distal to the occlusion

Calf pain: femoral-popliteal disease

Calf and thigh pain: common femoral artery

Thigh, hip, buttock pain with impotence: aortoilliac disease

Question 23

What is on your differential for chronic lower extremity pain?

Answer 23

Chronic arterial occlusive disease

Spinal stenosis (pseudoclaudication)

Spinal cord tumors

Lumbar radiculopathy

Degenerative joint disease

DVT

Question 24

How does spinal stenosis (pseudoclaudication) typically present?

Answer 24

Pain when walking downhill

Back is hyperextended

Better when walking with a grocery cart (back flexion)

Pain lasts for hours afterward

Question 25

What is the normal ankle-brachial index range?

Answer 25

0.9- 1.4

Question 26

What is the range for a mild and moderate ankle - brachial index?\*\* reword question

Answer 26

Mild- 0.7- 0.89 Moderate 0.4- 0.69

Question 27

What is a severe score for ankle-brachial index testing?

Answer 27

Less than 0.4

Question 28

How do you interpret an ankle-brachial index of 1.4 or greater?

Answer 28

Indicates non-compressible arteries Calcified vessels

Question 29

Patient has their blood pressure measured in both arms, however there is a systolic BP difference of \>20 mm Hg between the arms. Diagnosis, treatment?

Answer 29

Subclavian artery stenosis Due to atherosclerosis If asymptomatic no intervention needed Intervene if having subclavian steal syndrome, upper extremity claudication, coronary steal syndrome

Question 30

How is peripheral artery disease treated?\*\*

Answer 30

_Risk factor modification:_ Smoking cessation HTN and DM control Antiplatelet therapy (ASA OR Clopidogrel)- not DAPT _Interventions:_ Exercise Cilostazol Lipid lowering agents Ramipril

Question 31

How does exercise improve PAD?

Answer 31

Improve pain free walking by about 90 yards No change in ABI

Question 32

How do lipid lowering agents improve PAD?

Answer 32

Improve pain free walking by about 96 yards

Question 33

How does Cilostazol (Pletal) improve PAD?

Answer 33

Inhibits phosphodiesterase type 3 Improves pain free walking by about 41 yards

Question 34

Can ACE inhibitors be used to treat PAD?

Answer 34

Only Ramipril has been studied (10 mg daily) Increases pain free walking and total walking time

Question 35

What is the role imaging in managing PAD?

Answer 35

Imaging when considering revascularization Localizing the lesion

Question 36

What are the symptoms of critical leg ischemia?

Answer 36

Unstable angina of the leg Pain at rest in foot or toes Pain worse with legs elevated, relieved with legs dependent (hanging off edge of bed) Leg edema

Question 37

What skin changes are seen as PAD progresses?

Answer 37

Hair loss, smooth, shiny skin, thick nails Pallor with leg elevation Rubor with legs dependent Bruits, decreased pulses Cyanosis, ulceration, gangrene

Question 38

What type of ulcer is this?

Answer 38

Venous stasis Shallow/flat ulcer with exudates and granulation tissue *https://www.nejm.org/doi/full/10.1056/NEJMra1615243*

Question 39

What type of ulcer is this?

Answer 39

Arterial ulcer Punched out, deep ulcer with necrotic/black coloring No exudate https://www.nejm.org/doi/full/10.1056/NEJMra1615243

Question 40

What type of ulcer is this?

Answer 40

Neuropathic Diabetic ulcer Deep ulcer surrounded by callous with lack of sensation https://www.nejm.org/doi/full/10.1056/NEJMra1615243

Question 41

What type of ulcer is this?

Answer 41

Pressure ulcer Deep, macerated ulcer https://www.nejm.org/doi/full/10.1056/NEJMra1615243

Question 42

Common location of venous v. arterial v. neuropathic v. pressure ulcers?

Answer 42

Venous - Between lower calf and medial malleolus Arterial - Pressure points, toes/feet, lateral malleolus, tibial areas Neuropathic - Plantar foot, tip of toes, lateral metatarsals Pressure - Bony prominences, heel

Question 43

Underlying causes and leg condition seen in patients with venous ulcers?

Answer 43

Varicose veins, Hx of DVT, obesity, pregnancy, recurrent phlebitis Skin: hemosiderin staining, thick, fibrosis, eczematous, itchy Limb edema, normal capillary refill

Question 44

Underlying causes and leg condition seen in patients with arterial ulcers?

Answer 44

DM, HTN, smoking, Hx of vascular disease Skin: thin shiny cool skin, lack of hair, pallor on elevation, gangrene Absent/weak pulses, delayed capillary refill

Question 45

Underlying causes and leg condition seen in patients with neuropathic ulcer?

Answer 45

DM, trauma, prolonged pressure Skin: Dry, cracked, calluses Decreased sensation

Question 46

Underlying causes and leg condition seen in patients with pressure ulcers?

Answer 46

Limited mobility, bed bound, frail Atrophic skin Decreased muscle mass

Question 47

Treatment of venous ulcers?

Answer 47

Compression socks, leg elevation, surgery Compression is just as effective as surgery If compression sock show no improvement, surgery will not offer much benefit either

Question 48

Treatment of arterial ulcers?

Answer 48

Manage risk factors Anti-platelet medication (ASA or Plavix) Revascularization

Question 49

Treatment of neuropathic ulcers?

Answer 49

Off load pressure Daily foot checks/care Topical growth factors

Question 50

Treatment of pressure ulcers?

Answer 50

Off load pressure Reduce moisture, shearing/friction forces Maintain adequate nutrition

Question 51

How often should at-risk but asymptomatic patients be screened with ABI, per USPTF?

Answer 51

Insufficient evidence for routine screening

Question 52

How does acute arterial occlusion present?

Answer 52

Pain Pallor Parenthesia Pulselessness Paralysis Poikolosis (cold)

Question 53

In acute arterial occlusion, where do emboli come from and where do they commonly lodge?

Answer 53

Heart- most common source LE bifurcation, cerebral arteries, upper extremities, visceral arteries (SMA occlusion)

Question 54

Patient with HTN, HLD, smoker presents with dusky painful toes. No trauma, no hx of afib. Posterior tibial pulses 2+, dorsalis pedis pulses 1+. Diagnosis?

Answer 54

Blue Toe Syndrome

Question 55

What is the pathophysiology of Blue Toe Syndrome?

Answer 55

Cholesterol or atherothrombic emboli occluding small vessels Can look like bruising Can have normal pulses Can effect multiple organs (especially kidneys) Not a blood clot or plaque emboli

Question 56

How is the diagnosis of Blue Toe Sydrome confirmed and what is the treatment?

Answer 56

Skin or muscle biopsy- cholesterol crystals No reversal agent No anticoagulation needed

Question 57

What is Raynaud’s phenomenon?

Answer 57

Recurrent vasospasm of the fingers, toes and/or tip of nose in response to stress or cold exposure Cause: Idiopathic v. Association with rheumatic illnesses