Peripheral Vascular Disease Flashcards
what are the signs of arteriosclerosis of peripheral artery?
PAD
- poor pulses, slow cap-refill, bruits
- claudication
- poor healing
- erectile dysfunction
- hair loss
what are the biggest risk factors for developing PVD in lower extremities?
tobacco & diabetes
What history findings indicate advanced PAD?
pain at rest or foot ulcers
Developing sudden pain & numbness in UE with not history of claudication indcates what?
Peripheral arterial embolism
what PE findings indicate peripheral arterial embolism?
absent pulse, pale & cold extremity
what is treatment plan for PAD?
- dialy exercise
- foot care
- smoking cessation
- debridement (if ulcered)
- antiplatelet & statin
Cilostazol, aspirin, clopidogrel
What treatment is indicated for severe claudication or pain at rest with PAD?
Revascularization
surgery or angioplasty + stent
what imaging is used to diagnosis most peripheral vascular disease?
- CTA
- MRA
- conventional angiography
MRA = magnetic resonance angiography; CTA = CT angiography
What segments are most common occluded in LE PAD?
- Aortoiliac
- Femoral-Popliteal
- Infrapopliteal or tibial
what are PE for PAD?
- ABI < 0.9
- Blanching with elevation
- Redness
- Ulcers/gangrene
what is the likely etiology of peripheral arterial embolus?
heart or aorta thrombus/vegetation
what treatment would be used for arterial embolism <2 weeks?
- IV heparin
- retelplase or tPA
-plase = thrombolytic
what LE findings would be from atheroembolism?
embolis from atheroma (fibrin, platlets, cholesterol)
Blue toe syndrome (gangrene)
what is treatment for atheroembolism?
supportive
what would you expect to see if a patient has thromboangiitis obliterans?
- superficial thrombophlebitis
- gangrene
- claudication
- heavy smoking history
what imaging findings would indicate thromboangiitis obliterans?
smooth tapering lesions
without proximal atherosclerosis
What steps are taken for buergers disease?
thromboangiitis obliterans
STOP SMOKING
Phases of Raynaud?
blanched -> blue -> red
How would 2º raynauds present?
AFTER cold exposure
* necrosis
* unilateral
* >50yo
1ºoften benign
what conditions are associated with 2º raynauds?
- CREST
- SLE
- dermatomyositis
- polymyositis
- atherosclerosis
- thoracic outlet syndrome (blood & sympathetic N. compression)
- 1º pulmonary HTN
- Waldenstroms macroglobulinemia
- ß-antagonists
- Chemo
what is treatment of Raynauds?
- Warm up
- dihydropyridines (-pine)
- a1-antagonists (prazosin)
- PDE5 inhibitors (-afil)
What is normal ABI?
0.9-1.2
what is ABI looking at?
ratio of SBP by doppler ankle - brachial A.
posterior tibial or dorsalis pedis -> whichever is HIGHER is used
If segmental waveforms or pulse volumes are found what does it indicate?
blunting of arterial flow
ABI of patient with claudication?
0.5 - 0.7
ABI in pain at rest?
0.3 - 0.5
ABI in with gangrene?
less than 0.3
Diabetics & end-stage renal disease may have ABI of
greater than 1.4 -> other test required
toe-brachial pressure
If a patient has suspected PAD but ABI is equivocal what would next test be to rule out PAD?
exercise testing + ABI
diabetics, end-stage renal patients, severe calcification
What would be expected in excercise ABI in a end-stage renal pt?
decrease in ABI
What diagnostic test ordered after ABI?
duplex US
can NOT determine severity
What may hinder analysis of CTA?
prior Stent or iodine allergy
Why use MRA over CTA?
- non-iodine contrast (gadolinium)
- not nephrotoxic
What is the gold standard for imaging vasculature?
Catheter angiography w/ contrast
What tests should be ordered suspecting DVT?
Doppler ultrasounds & D-dimer
what is the presentation of DVT?
- unilateral LE pain & swelling
- palpable cord
- low-grade fever
- Wells score >2
What is treatment for DVT?
- direct oral Factora Xa inhibitor (rivaroxaban)
- Heparin or enoxaparin
- IVC filter
- pneumatic compression and ambulation (prevention)
A 28yo white female comes in with HTN after being on ACEi, diuretic, & ß-blocker. What would your suspected Dx be?
2º HTN
What are causes of 2º HTN?
- Renal A. stenosis
- 1º aldosteronism
- sleep apnea syndrome
What should be looked for in suspected renal A. stenosis?
- refractory/new-onset HTN
- pulmonary edema
- poorly-controled BP
- AKI after starting ACE or ARB
What PE findings would indicate renal A. stenosis?
- abdominal bruit on affected side
what are two causes of renal A. stenosis?
- atherosclerosis (80-90%)
- fibromuscular dysplasia (10-15%)
what would indicate a patient has fibromuscular dysplasia causing renal artery stenosis?
Woman <40yo with unexplained HTN
What labs would indicate renal artery involvment?
- hypokalemia (b/l stenosis)
- elevated BUN & Cr
Renal artery stenosis on abdominal US would show?
- asymmetric kidneys (1 affected)
- small hyperechoic kidneys (2 affected)
When would MRA be more likely indicated for RAS?
suspected atherosclerotic disease
what treatments would be used if MRA shows RAS?
- manage BP
- lipid control (statin)
- glucose control
- smoking cessation
stenting or surgery controversial
what treatment is indicated for fibromuscular dysplasia in RAS?
angioplasty
what is the presentation of superficial thrombophlebitis?
red, tender, & edma along vein
treatment for superficial thrombophlebitis includes
heat, elevation, & aspirin
a patient comes in with a tender red edematous lesion on his right arm. To rule out lymphangiitis look for
- fever
- LAD
- red superficial streaks along lymphatics
a patient with non-pitting edema that is non-tender for the last 2 years comes. What labs should be ordered
Abd/Pelvic US, CT, or MRI for obstruction
looking to rule in lymphedema
Managment for lymphedema includes
- foot hygiene to prevent infection
- elevation
- compression
- AVOID diuretics
If a patient has lymphedema without a family history, what is a likely etiology?
- lymphangitis
- tumor
- surgery or radiation (trauma)
- filariasis
A patient with history of DVT is suspected of having chronic venous insufficiency (CVI), what are assocaited findings?
- progressive pitting edema
- hyperpigmented skin
- itching dull pain worse with standing
- ulcers above medial/anterior ankle
What may develop in a patient with longstanding CVI?
thick & fibrous subcutaneous tissue
lipodermatosclerosis
A patient with CVI has brown splotching around their ankle from what?
hemosiderin deposits
what is the primary treatment plan for CVI?
- fitted compression stockings
if compression stockings are not affective, what should be done for CVI?
Elevate, avoid prolonged sitting/standing, sleep with legs above heart
treating an ulcer in CVI requires
- debridement
- semi-rigid gauze boot (changed 2-3d)
change 5-7d once edema & drainage are managed
what is the benefit of using circumferential nonelastic bandages in CVI ulcers?
enhance venous pumping with calf muscles
In a CVI patient duplex US shows venous reflux, what would be the benefit of vein stripping?
decrease ulceration
If femoral or popliteal vein are severly blocked what should be avoided?
removing superficial vericose
they supply the venous return
If iliac is stenosed/obstructed what should be applied?
stents
