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01 Family Medicine > Peripheral Vascular Disease > Flashcards

Peripheral Vascular Disease Flashcards

AAFP Board Review lecture: PVD

1
Q

What is the normal diameter of the aorta?

A

1.8 - 2 cm

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2
Q

Define aneurysm

A

Any vessel that is >50% larger than normal

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

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3
Q

What demographics are higher risk for AAA?

A

Elderly

Men

Smoker

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4
Q

Where are the majority of AAAs found?

A

Infrarenal (below renal arteries)

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5
Q

What is the pathogenesis of most AAAs?

A

Atherosclerosis

Thoracic/suprarenal: Marfans, Ehlers-danlos, syphilis

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6
Q

What is the mortality of AAA rupture?

A

Overall 80%

60% die before arrival

Only 50% of those who arrived alive survive

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7
Q

What is the USPSTF guideline for AAA screening?

A

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

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8
Q

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

A

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

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9
Q

Does Medicare part B cover one time AAA screening?

A

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

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10
Q

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

A

5 - 5.5 cm

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11
Q

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

A

36 months

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12
Q

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

A

12 months

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13
Q

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

A

6 months

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14
Q

What are the highest risk demographics for aortic dissection?

A

40 - 80 years old

Males > females

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15
Q

What is the most common cause of aortic dissection?

A

HTN

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

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16
Q

Compare and contrast AAA and aortic dissection

A

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

AD- An intimal flap forms creating a second lumen

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17
Q

What is type A v. Type B aortic dissection?

A

A- Ascending aorta

B- Descending aorta (after subclavian artery)

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18
Q

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

A

A- anterior chest pain, tearing/ripping pain

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

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19
Q

What is the best imaging modality for aortic dissection?

A

CT angiogram

Others: TTE/TEE, MRI, aortography

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20
Q

What are the treatment goals of aortic dissection?

A

Lower BP (SBP 90-100)

Lower velocity of LV ejection

IV esmolol, nitroprusside

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21
Q

Define claudication

A

Reproducible ischemic muscle pain

Occurs with exercise, relieved with rest

Stable angina of the legs

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22
Q

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

A

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

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23
Q

What is on your differential for chronic lower extremity pain?

A

Chronic arterial occlusive disease

Spinal stenosis (pseudoclaudication)

Spinal cord tumors

Lumbar radiculopathy

Degenerative joint disease

DVT

24
Q

How does spinal stenosis (pseudoclaudication) typically present?

A

Pain when walking downhill

Back is hyperextended

Better when walking with a grocery cart (back flexion)

Pain lasts for hours afterward

25
Q

What is the normal ankle-brachial index range?

A

0.9- 1.4

26
Q

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

A

Mild- 0.7- 0.89

Moderate 0.4- 0.69

27
Q

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

A

Less than 0.4

28
Q

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

A

Indicates non-compressible arteries

Calcified vessels

29
Q

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?

A

Subclavian artery stenosis

Due to atherosclerosis

If asymptomatic no intervention needed

Intervene if having subclavian steal syndrome, upper extremity claudication, coronary steal syndrome

30
Q

How is peripheral artery disease treated?**

A

Risk factor modification:

Smoking cessation

HTN and DM control

Antiplatelet therapy (ASA OR Clopidogrel)- not DAPT

Interventions:

Exercise

Cilostazol

Lipid lowering agents

Ramipril

31
Q

How does exercise improve PAD?

A

Improve pain free walking by about 90 yards

No change in ABI

32
Q

How do lipid lowering agents improve PAD?

A

Improve pain free walking by about 96 yards

33
Q

How does Cilostazol (Pletal) improve PAD?

A

Inhibits phosphodiesterase type 3

Improves pain free walking by about 41 yards

34
Q

Can ACE inhibitors be used to treat PAD?

A

Only Ramipril has been studied (10 mg daily)

Increases pain free walking and total walking time

35
Q

What is the role imaging in managing PAD?

A

Imaging when considering revascularization

Localizing the lesion

36
Q

What are the symptoms of critical leg ischemia?

A

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

37
Q

What skin changes are seen as PAD progresses?

A

Hair loss, smooth, shiny skin, thick nails

Pallor with leg elevation

Rubor with legs dependent

Bruits, decreased pulses

Cyanosis, ulceration, gangrene

38
Q

What type of ulcer is this?

A

Venous stasis

Shallow/flat ulcer with exudates and granulation tissue

https://www.nejm.org/doi/full/10.1056/NEJMra1615243

39
Q

What type of ulcer is this?

A

Arterial ulcer

Punched out, deep ulcer with necrotic/black coloring

No exudate

https://www.nejm.org/doi/full/10.1056/NEJMra1615243

40
Q

What type of ulcer is this?

A

Neuropathic Diabetic ulcer

Deep ulcer surrounded by callous with lack of sensation

https://www.nejm.org/doi/full/10.1056/NEJMra1615243

41
Q

What type of ulcer is this?

A

Pressure ulcer

Deep, macerated ulcer

https://www.nejm.org/doi/full/10.1056/NEJMra1615243

42
Q

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

A

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

43
Q

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

A

Varicose veins, Hx of DVT, obesity, pregnancy, recurrent phlebitis

Skin: hemosiderin staining, thick, fibrosis, eczematous, itchy

Limb edema, normal capillary refill

44
Q

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

A

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

45
Q

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

A

DM, trauma, prolonged pressure

Skin: Dry, cracked, calluses

Decreased sensation

46
Q

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

A

Limited mobility, bed bound, frail

Atrophic skin

Decreased muscle mass

47
Q

Treatment of venous ulcers?

A

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

48
Q

Treatment of arterial ulcers?

A

Manage risk factors

Anti-platelet medication (ASA or Plavix)

Revascularization

49
Q

Treatment of neuropathic ulcers?

A

Off load pressure

Daily foot checks/care

Topical growth factors

50
Q

Treatment of pressure ulcers?

A

Off load pressure

Reduce moisture, shearing/friction forces

Maintain adequate nutrition

51
Q

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

A

Insufficient evidence for routine screening

52
Q

How does acute arterial occlusion present?

A

Pain

Pallor

Parenthesia

Pulselessness

Paralysis

Poikolosis (cold)

53
Q

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

A

Heart- most common source

LE bifurcation, cerebral arteries, upper extremities, visceral arteries (SMA occlusion)

54
Q

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?

A

Blue Toe Syndrome

55
Q

What is the pathophysiology of Blue Toe Syndrome?

A

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

56
Q

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

A

Skin or muscle biopsy- cholesterol crystals

No reversal agent

No anticoagulation needed

57
Q

What is Raynaud’s phenomenon?

A

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

01 Family Medicine (16 decks)

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