Peripheral vascular disease Flashcards
What is Raynaud’s phenomenon?
Paroxysmal digital vasoconstriction
- Intermitten bilateral symmetrical pallor
- Tissue blanching
- Cyanosis followed by rubor of hands (rarely feet)
Raynaud’s phenomenon clinical presentation
- Intense itchiness → tissue blanching or pallor
- Progressive symptoms
- Triggers: exposure to cold, emotional upset
- Use of vibrating tools, repeated sharp digit movement (playing piano), frostbite, tobacco, ergotamine, beta blocker
Raynaud’s phenomenon diagnostic testing
Diagnosis made based on history and physical exam
- Symptoms must be present for more than 3 years without notation of associated disease or secondary cause
Raynaud’s phenomenon treatment and management
- Avoid known triggers
- Submerge hands in warm water at onset of episode
- Protect hands from minor injuries (wound healing is slow)
- Keep hands well lubricated
- Smoking cessation
- CCBs, ACE inhibitors, ARBs for vasodilator effect
Risk factors for varicose veins
- Leg crossing
- Wearing constricting clothing
- Prolonged standing
- Heavy lifting
- Current or prior pregnancy
Varicose veins treatment and management
- Maintain normal weight
- Periodic leg elevation
- Medium weight to heavy weight elastic supports
- Avoid wearing constricting garments
- Sclerotherapy
- Endovenous laser ablation
Virchow’s triad - three factors that contribute to thrombosis
- Blood stasis
- Injury to vascular intima
- Abnormal coagulation leading to clot formation (hypercoagulability)
Superficial thrombophlebitis clinical presentation
Should be assessed after patient has been standing for 2 minutes
- Extension into a deep vein is typically present
- Likely to be associated with DVT or PE in hospitalized patients
- May be complication of varicose veins
Superficial thrombophlebitis treatment and management
- Warm packs
- Compression hose
- NSAIDs
- Encourage ambulation
- Leg elevation if there is edema
DVT diagnostic testing
- Compression duplex venous US
- Serial studies needed if initial examination is negative but symptoms persist
- Can be done while pregnant
- Monitor for signs of PE → SOB, tachypnea, pleuritic friction rub
- Labs: d-dimer
DVT clinical presentation
- Edema
- Leg pain
- Calf swelling
- Homans sign: pain on dorsiflexion of foot
- PE s/s
DVT treatment and management
First line → direct oral anticoagulants (DOACs)
- Direct factor Xa inhibitors → rivaroxaban (xarelto), apixaban (eliquis), edoxaban (savaysa)
- Direct thrombin inhibitor → dabigatran (pradaxa)
Contraindications to DOAC therapy
Use heparin for DVT therapy if there are contraindications
- Antiphospholipid antibody syndrome
- Extremes of weight (less than 110 lbs or greater than 265 lbs), BMI >35
Pulmonary embolism clinical presentation
- Dyspnea
- Pleuritic chest pain
- Pleural friction rub
- Accentuation of pulmonic component of S2 heart sound
- Tachypnea
- Tachycardia
- Uncommon: hemoptysis, cyanosis, change in LOC
Pulmonary embolism diagnostic testing
- Wells criteria/Geneva score
- Coagulation studies (d-dimer)
- Pulmonary CT
Pulmonary embolism treatment and management
- Long term (3 months) anticoagulant therapy → DOAC preferred
- If patient experiences recurrent DVT or PE while on therapy, switch to LMWH for 1 month
What is peripheral vascular disease?
Reduction of blood flow to extremities
- Venous, arterial, and/or lymphatic system is affected
Peripheral vascular disease clinical presentation
- Claudication: reproducible calf muscle pain worse with exertion, relieved by rest
- Burning sensation or ache with walking
- Foot pain at rest
- Numbness, coldness, pain in extremity
- Nail thickening
- Dependent rubor, blanching of foot with elevation
Peripheral vascular disease diagnostic testing
- Ankle-brachial index (<0.95 = PAD)
- Doppler US
Peripheral vascular disease treatment and management
- Smoking cessation
- BP, glucose, lipid control
- Statin therapy
- Encourage exercise
- Meticulous skincare to prevent skin breakdown (podiatrist)
- Antiplatelet therapy
- ASA or clopidogrel
- If anticoagulation is needed → DOACs
Can peripheral arterial occlusive disease, although slowly progressive, lead to acute limb ischemia?
Medical emergency
Yes - caused by embolic, thrombotic, traumatic events (6 P’s)
- Pin
- Paresthesia
- Pallor
- Pulselessness
- Poikilothermy (variation in skin temp)
- Paralysis
If d/t acute arterial occlusion, start anticoagulation therapy with heparin
What is chronic venous insufficiency?
Sequela of DVT and leg trauma
Functional changes that occur in LEs d/t persistent elevation of venous pressures
Decreased venous return because of vessel damage
Chronic venous insufficiency clinical presentation
- LE edema is earliest sign
- Thin, shiny atrophic skin with brown pigmentation
- Leg aching and cramping
- Heaviness
- Itch
- Sensation of leg fatigue
- Stasis ulceration
Chronic venous insufficiency treatment and management
- Limb elevation, exercise, compression therapy
- If compression is not successful, pentoxifylline
- Wound debridement
- Adequate nutrition (protein)
