Peripheral Vascular Disease

Question 1

Arterial stenosis is usually a result of what?

Answer 1

Atherosclerosis

Question 2

Venous stenosis is usually a result of what?

Answer 2

Thrombosis

Question 3

list 4 PAD risk factors

Answer 3

Diabetes (4-fold increased risk)
Smoking (2-3 X)
Lipids (2 X)
Hypertension (2X)

Question 4

Are PAD patients at increased risk for CV death?

Answer 4

YES. 6-fold increased risk of CV death

Question 5

What are the manifestations of PAD?

Answer 5

-Intermittent Claudication

Question 6

describe blood flow in intermittent claudication

Answer 6

Blood flow normal at rest (no Sx), limited with exercise (Cramp, calf fatigue )

Question 7

Describe the blood flow resulting in Ischemic rest pain/ischemic ulcers

Answer 7

Blood flow limited at rest and exercise (constant Sx)

• Pain in the distal foot or heel, worsened by leg elevation and improved by dependency
• Distal, painful ulcers on toes or heel

Question 8

List some physical findings in patients with PAD

Answer 8

Decreased or absent pulses
Bruits (abdominal, femoral)
Muscle atrophy
Pallor of feet with elevation (Severe PAD)
Dependent rubor (Severe PAD)

Question 9

What determines the severity of atrial stenosis?

Answer 9

Radius & length of the stenosis

Question 10

What is the ABI index?

Answer 10

Ankle-Brachial Index, looks at the extent of peripheral stenosis by comparing arm BP to ankle BP.
Ankle SBP/Arm SBP = ABI
Ratio < 0.90 = PAD

Question 11

What are the treatment GOALS for claudication?

Answer 11

• Prevent CV events (MI, stroke, vascular death)
• Improve limb symptoms, exercise performance and QOL
• Heal ulcers and prevent limb loss

Question 12

What treatment options do you have for claudication?

Answer 12

Surgery or angioplasty improves hemodynamics
Exercise training improves muscle metabolism
Drugs (cilostazol) have multiple mechanisms

Question 13

What is an arterial aneurysm?

Answer 13

Pathological expansion of all three arterial layers

Question 14

Normal diameter of the aorta

Answer 14

3 cm at its root;
2.5 cm mid descending thoracic aorta;
2 cm at the infra-renal aorta

Question 15

When would you classify an expansion in the abdominal aorta as a AAA?

Answer 15

• denoted by diameter of > 3.0 cm

- Or 50% increase in size relative to proximal normal segment

Question 16

List the 4 mechanisms leading to aortic aneurysm formation

Answer 16

-Weakened Aortic Wall (low collagen/elastin)

Question 17

What is the 13th leading cause of death in the US?

Answer 17

Ruptured aneurysms, Annual incidence estimated 40 to 50 per 100,000 men and 7 to 12 per 100,000 women

Question 18

AAA risk factors

Answer 18

Age
Gender
Smoking
Family history

Question 19

How do AAA patients present?

Answer 19

• 70% of patients are asymptomatic, then present with sudden death
• 30% present with abdominal discomfort or severe pain radiating to the back, then die

Question 20

What diagnostic tests can be used to Dx AAA?

Answer 20

Plain X-ray
Ultrasound
Computerized tomography
Magnetic resonance imaging
Arteriography (May miss it because angiography views the lumen not the arterial wall)

Question 21

Prevalence of aortic dissections

Answer 21

~ 30 cases / million / yr

3-5 % sudden deaths

Question 22

What are the 2 mechanisms of aortic dissection?

Answer 22

Primary Intimal Rent/Tear

Question 23

Risk factors leading to aortic dissection

Answer 23

Hypertension (drugs e.g. cocaine)
Inherited disorders of connective tissue
Marfan syndrome
Ehlers-Danlos syndrome
Bicuspid aortic valve 
 and more...

Question 24

Presentation of pts w/ aortic dissection

Answer 24

-C/o severe, tearing pain
-Disruption of major arterial circulation leads to:
Stroke (carotid)
Syncope (vertebral)
Myocardial infarction (coronaries)
Intestinal ischemia (mesenteric vessels)
Renal failure (renal arteries)

Question 25

medical Tx of aortic dissections

Answer 25

• Control of Pressure/Time: Beta Blockade
• Control of Blood Pressure: Nitroprusside, ACE inhibitors, Calcium Channel Blockers
• Control of Pain: Narcotic analgesia

Question 26

T or F: Nearly 2/3 of VTE are asymptomatic or undiagnosed

Answer 26

True

Question 27

Prevalence of VTE in patients w/ hx of MI, stroke & hip surgery

Answer 27

24% of MI patients develop VTE
60% of paralytic stroke patients develop VTE
75% of hip surgery patients develop VTE

Question 28

Stages of chronic VTE

Answer 28

Stage 1: swelling
Stage 2: Visible collateral’s
Stage 3: stasis dermatitis
Stage 4: ulcers

Question 29

Components of Virchow’s triad

Answer 29

Injury
hypercoagulability
Abnormal flow (stasis)

Question 30

Mechanisms of thrombophilia

Answer 30

Imbalance in coagulation that causes the following:

• increases thrombin production
• enhances platelet activation/aggregation
• mediates endothelial activation/damage
• and/or mediates fibrinolytic inhibition

Question 31

Thrombophilia risk factors

Answer 31

• Severe inherited thrombophilia (homozygous protein C deficiency) is rare
• Mild inherited thrombophilia (heterozygous Factor V Leiden) is common
• Acquired thrombophilia is especially common in infection, inflammatory and certain drugs

Question 32

Parenteral Xa inhibitors

Answer 32

Heparin, LMWH

Question 33

Parenteral direct thrombin inhibitors

Answer 33

Argatroban, Dabigatran (can be oral as well)

Question 34

Direct oral inhibitors of Xa

Answer 34

Apixaban

Question 35

Oral anticoag targeting II, VII, IX, X

Answer 35

Warfarin