Peripheral Vascular Disease Flashcards
Peripheral Vascular Disease
Lower extremity disease of reduced blood flow due to presence of atherosclerotic plaques
Cause of PVD
Atherosclerosis
RFs of PVD
Smoking (most important)
HTN
Hyperlipidemia
Diabetes
Claudication in LE PAD (3 sxs)
Leg pain with walking
Several minutes of rest alleviate pain
Pain is reproducible at the same walking distance & intensity
MC site of Peripheral Atherosclerosis
Superficial Femoral Artery
- Level of Adductor (Hunter’s) canal
Muscle group commonly affected by claudication in PAD
Calf muscle (supplied by SFA)
What arteries are artherosclerosed in Aortoiliac occlusive disease?
- Infrarenal Aorta
- Common iliac arteries
Triad for Aortoiliac Occlusive Disease
- Claudication of low back, buttocks, hip or thigh
- Absent or diminished femoral pulses
- Erectile dysfunction
CFs of LE PAD
- Dry, shiny & scaly skin
- Hairless
- Brittle & thickened toenails
What symp. indicated severe PAD? (2)
- Ischemic rest pain
- Impending limb loss
Characteristic features of Ischemic rest pain
Nighttime forefoot or toe pain that awakens pts. from sleep
- Better by placing leg in dependent position and
Mechanism of ischemic rest pain
Laying in bed reduces gravity-assisted blood flow –> Ischemia
Beurger test (steps)
Observing foot perfusion w/ pt. in supine position:
1. Raising legs to 45 degrees for 1-2 mins –>
2. Placing leg in dependent position
+ve Beurger test (results & indication)
- Pallor on elevation
- Rubor in dependent position
- Indicated severe PAD
Reason for Rubor during Beurger test
Compensatory arteriolar dilation & reactive hyperemia
Cause of Neurogenic claudication
Nerve root compression in the setting of Lumbar spinal stenosis
CFs of Neurogenic claudication
B/l & asymmetric- leg pain, sensory loss & weakness
Worse w/ walking & erect postures
Better w/ sitting, lying down & leaning forward
CFs of Acute Lumbosacral Radiculopathy/ S1 Radiculopathy
- Lower back pain
- Radiates down posterior thigh into foot
- Dec sensation in posterior thigh & lateral edge of foot
- Loss of ankle reflex
Test-of-choice for diagnosis of Arterial stenosis or Occlusion in setting of suspected PAD
Resting Ankle-Brachial Index (ABI)
- <0.4 –> Severe PAD (rest pain)
- 0.4 - 0.9 –> Moderate PAD (claudication)
- 0.91 - 1.3 –> Normal
- >1.3 –> Unreliable (incompressible vessel)
Disease that are associated with ABI > 1.3
- Diabetes Mellitus
- ESRD
D/t Medial calcinosis
Other Diagnostic test
- Arterial duplex scans
- CT angiogram
Arterial Duplex scans
Ultrasound (identify a. plaques) + Doppler (detect elevated blood flow velocity –> stenosis is hemodynamically relevant)
- Triphasic –> Normal
- Biphasic –> Single-level / Moderate PAD
- Monophasic –> Multi-level/ Severe PAD
Gold standard for localizing areas of vessel stenosis
CT-angiography
- reserved for pts. planning to undergo invasive therapeutic interventions
Management of Mild-to-Moderate PAD w/ claudication
- Supervised exercise therapy ( inc. collateral circulation)
- Smoking cessation
- Antihypertensives
- Statins
- Antiplatelets (aspirin or Clopidogrel)
*Dec Cardiovascular risk) - Cilostazol (PDE3 Inhibitor) - Improve walking distance in pts. w/ claudication refractory to lifestyle modification & medical therapies
Mechanism of PDE3-Inhibitors
- Inhibits platelet aggregation.
- Promotes vasodilation
- Inhibits smooth muscle cell proliferation
Management of all pts. w/ PAD
Invasive revascularization
- Percutaneous transluminal angioplasty w/ or w/o stenting.
- Bypass grafting
- Limb amputation (severely diseased)
Acute LE Occlusion
Sudden onset of impaired perfusion that threatens limb viability
CFs of Acute LE Occlusion (6 P’s)
- pulselessness
- Pain
- Pallor
- Poikilothermic (cold)
- Paresthesia
- Paralysis
MCC of Acute LE Occlusion
CARDIAC EMBOLI
- A. fib (MC)
- Post MI
- Valvular disease
- Atrial myxoma
- CHF? Cardiomyopathy
- L. atrium MC site of origin for emboli*
MC location of Arterial embolization or Acute LE Occlusion
Common Femoral Artery Bifurcation –> Superficial Femoral A. + Profunda femoral A.
How long does it take for complete cell damage to occur?
> 6 hours
- Severe limb impairment & maybe amputaion
Imaging for ALEO
- CT angiogram (gold standard)
- Emergent open embolectomy (ballon or Fogarty catheter)
Management of ALEO
- Heparin
- IVF
- Placement of affected limb in dependent position
- Even before imaging is done*
- Mild occlusion –> Endovascular thrombolysis
- Irreversible damage- Amputation
MCC of Acute Arterial Limb Ischemia
Arterial embolism
MC location of Acute Arterial Limb Ischemia
LE»_space; UE
MCC of arterial embolization
- Atrial thrombi <– A. fib
- Mural thrombus <– Recent MI
How soon should reperfusion of limb w/ thrombolytic occur before muscles become necrotic?
Within 6 hours
How should Heparin anticoagulation be given?
IV bolus followed by continuous Heparin drip
- 1st step of Tx
How to prevent Compartment syndrome?
Fasciotomy
Surgical procedure of choice for pts. w/ acute arterial limb ischemia
Fogarty ballon catheter embelectomy
