Peripheral Vascular Disease Flashcards
PVD affects ___% of people over the age of ____ years.
20%
70 yoa
PVD can affect what three things?
arteries
veins
lymphatics
Two different disease processes in PVD
occlusive disease
aneurysmal disease
Prevalence of PVOD
- Age:
- ABI
40yrs
PVOD affects _____ american
every - even young adults have fatty streaks in their aorta
Prevalence of PVOD:
1. 70 years old:
Affects ____ million people
- 0.9%
- 14.5%
8-12million
Gender differences in PVOD: Age: state male vs female 1. 40-49: 2. 50-59: 3. 60-60: 4. >70
- M 1.1% F 0.6%
- 3.1% F 1.9%
- 6.7% 2.8%
- 13.7% 15.0%
What are the risk factors for PVD (9)
- Gender (male)
- age
- DM
- Smoking - severity proportional to the number of cigarettes smoked
- HTN
- Dyslipidemia
- Homocysteinemia
- Renal insufficiency
- Metabolic syndrome (three of the four)
What four criterion make up metabolic syndrome
- BP elevation (>130/85)
- Triglycerides >150mg/dl
- Fasting blood sugar >100
BMI >30 or waist circumference >102cm (men) and 88 cm (women)
Diagnosis of PVOD reduces life expectancy by _____
10 years
Mortality if diagnosed wiht PVOD:
5 year
10 year
15 year
25%
50%
70%
at 5 years, how does survival rates compare to breast cancer, colon cancer, cervical cancer PVOD
Breast cancer 86%
Colon Cancer 62%
Cervical cancer 71%
PVOD 70%
at 10 years, how does survival rates compare to breast cancer, colon cancer, cervical cancer PVOD
breast cancer 78%
colon cancer 62%
Cervical cancer 54%
PVOD 50%
at 15 years, how does survival rates compare to breast cancer, colon cancer, cervical cancer PVOD
breast cancer 71%
Colon cancer 50%
Cervical cancer 53%
PVOD 30%
Risk to patient with claudication of progressing to critical limb ischemia?
1% per year
Motrality from cardiac or cerebrovascular disease?
5-10% per year
Risk for death is ______ x higher than risk of limb loss
5-10x
Severity of PVOD comes in three flavors
Asymptomatic (essentially every american) Claudicatiion Critical limb ischemia - rest pain - ischemic ulceration - gangrene
Naem the fontaine classification of PVOD
I asymptomaticc IIa mild claudication IIb moderate-severe claudication III rest pain IV ulceration or gangrene
Name the rutherford classification of PVOD
Grade, Category, Clinical:
0, 1, asymptomatic I, 1, Mild claudication I, 2, moderate claudication I, 3, severe claudication II, 4, Rest pain III, 5, Minor tissue loss III, 6, Major tissue loss
A 65-year-old man comes to your office with complaints of pain in his left foot. The patient is on medication for HTN, had a coronary stent placed two years ago, smokes between one and two packs per day, and has been on oral hypoglycemic medication for 10 years. On further questioning, he states that he is able to walk only 100 feet before developing pain in his left calf that resolves with 5 – 10 minutes of rest. For the past month, after sleeping for 2 or 3 hours, he wakes up with pain in his left foot. This resolves when he gets up to use the bathroom. Based on this history:
He has severe diabetic neuropathy
The patient has a lumbar nerve compression causing his pain
You anticipate that the patient will likely need an operation
It is likely that the patient has a stenosis of the superficial femoral artery
C
_____ is reproducilble pain in a muscle group brought on by exercise and relievedby rest
Claudication
In claudication, muscle group is affected generally by _____
one level below the site of occlusive disease
Thigh vs peroneal veines
Claudication is due to
inadequate perfusion to meet the metabolic demands of skeletal muscle metabolism
____ is pain in the toes/forefoot that typically occurs at night and awakens the patient, relieved by dependency
rest pain - perfusion is margenal, requires gravity to maintain tissue perfusion
_____ tissue is the most sensitive to ischemia
nerve tissue
Rest pain is considered
= critical limb ischemia
In patients with leg pain, claudication will be the cause in _____% of patients
30-85%
patients with leg pain and claudication progress to CLI in ____%
5-10%
CLI represents ____% of all patients with leg pain
1-3%
- rest pain
- ischemic ulceration
- gangrene
What are the 9 DDx for PVOD
- Neurogenic claudication (spinal stenosis)
- Arthritis
- Trauma (muscle tear, strains, bruises)
- Neuropathy
- DM
- nerve compression - Myalgia, myopathies
- CRPS (reflex sympathetic dystrophy)
7 Venous disease
- superficial thrombophlebitis
- DVT - Atheroembolization
- Buerger’s disease
Symptoms of PVOD
Onset:
Exercise induced:
Relief with stopping:
Predictable
Yes
Yes
Which ulcer? \+ pain \+ necrosis - venous stasis changes abnormal pedal pulses Location toes/foot
ischemic ulcer
Which ulcer? \+/- pain \+/- necrosis \+ venous stasis changes \+ normal pulses Location gaiter area
venous stasis ulcer
which ulcer? No pain \+/- necrosis - venous stasis changes \+ normal pedal pulses Location pressure points
Neurotrophic ulcer
Which Gangrene? Desiccated tissue, general hard, eschar Little to no odor No systemic or local signs of infection
dry
Which gangrene? Foul odor purulence, gas expressed moist, macerated tissue systemic and/or local signs of infection - fever - leukocytosis - cellulitis
wet
A 75 year-old man is being seen in your office for right lower extremity leg pain. He has a history of hypertension, hypercholesterolemia, prior MI treated with a coronary stent, carotid endarterectomy, and diabetes. You are suspicious that he has peripheral vascular occlusive disease. Which of the following would provide you with the most information to confirm your clinical suspicion, determine the severity of the disease, and direct recommendations for treatment?
Duplex scan of the lower extremity arteries with ABIs
CTA – aorta and run off
Lower extremity angiography
History and physical examination
D
What four things help with PVOD diagnosis
History
PE
Vascular lab eval
imaging studies
What are the 5 risk factors for PVOD when history taking
- associated CAD
- smoking
- diabetes
- ESRD
- hypercholesterolemia
what part of the history establishes the diagnosis?
claudication
Which vessel?
- thigh/buttock
- calf
aorto-iliac disease
SFA disease
With claudication, what part of this history shows severity of the disease
walking distance until onset of symptoms
What three things in H and P directs therapy?
- evidence of rest pain
- ulceration
- gangrene
____ exam is the corner stone for PVD
pulse exam
Normal (2+)
Diminished (1+)
Absent (0)
Examine: Radial, brachial, aorta, femoral, popliteal, DP, PT
What two physical exam findings would suggest ischemia induced vasodilatation
pallor on elevation
dependent rubor
what are three trophic changes to suggest PVD
thin skin
thickened nails
hair loss
What are two PE signs of critical limb ischemia
ulceration
gangrene
diagnosis Normal pulse exam at rest With exercise: Loss of distal pulses Drop in ABI Exercise causes vasodilation, decreased resistance Shift of “curve” to the left Lesser stenosis results in pressure drop
subcritical stenosis; claudication
____ measures limb perfusion that can be compared over time.
how performed?
Ankle brachial index (ABI): measurement of limb perfusion that can be compared over time
Systolic BP in both arms
BP cuff placed just proximal to the ankle
Doppler to determine systolic pressure for DP and PT
Highest ankle pressure divided by Highest arm pressure
Calcinosis is found primarly in ____ and _____
DM and ESRD
Calcinosis is found to be what on ABI?
non-compressible
ABI >1.4, therefore inaccurate
Measure toe pressure (digital artery is usually spared)
What is the ABI for the right leg?
BP R 150/80 L100/70
PT 50
DP 75?
0.5
What is the ABI for the left leg?
BP R 150/80 L 100/70
PT 75
DP 60
0.5
ABI values: Normal: Claudication: Rest pain: Tissue loss:
> 0.85
- 5-0.85
- 3-0.5
what are the four tests that can be performed in vascular laboratory
ABIs
Segmental pressures and waveform analysis
ABIs with exercise
Duplex examination - -Time consuming
Pros (2) and cons (3) of CT angiography
Pros:
- Non-invasive
- Assess arterial anatomy, may have information about veins
Cons:
- Large contrast bolus
- Vessel calcification, small vessels difficult to assess
- Need radiation, increased dose for obese patients
Conventional angiography uses _____ contrast than CTA
two pros?
contrast
can use CO2 (beneficial for renal insufficiency)
can intervene at time of study (angioplasty/stent)
MR angiography typically _____ severe stenosis
over reads
What are the 6 best risk factor modifications for PVD
Smoking cessation Diagnose and treat hyperlipidemia (Statins) Glucose control of diabetes Hypertension control ACE inhibitor Folate (homocystenemia)
In what 4 ways does exercise help with PVD
- Develops additional collateral flow
- Improves tolerance/increase muscle efficiency
- Improves walking distance 80 – 234%
- Long-term outcome is similar to surgical revascularization
What are the two antiplatelet agents used for PVD
ASA/plavix
What are the four ways that statins help with PVD
- Improve endothelial function
Upregulate eNOS
Vasodilation - Inflammatory response reduction
Reduce C-reactive protein
Inhibit macrophages - Anti-thrombotic effects
decreases platelet aggregation/adhesion
Reduce viscosity - Plaque stabilization
ACE Inhibitors doe what for PVD
reduce cardiovascular morbidity and mortality by 25%
What are the two rheologic agents used for PVD
Pentoxifylline (trental)
Cilostazol (Pletal)
cilostazol more effective
Vasodilators are effective for PVD in which disease
vasospastic disease (raynauds)
With Rheologic agents, _____% of patients will have clinical improvement
50%
Rheologic agents:
_____ trial period
To be used after ____ and _____
End point of medication:? (3)
3 month
smoking cessation and “failed exercise program”
- pain free walking distance
- absolute walking distance
- quality of life measurment
A 66 year-old man is seen in your office with classic symptoms of rest pain in his right foot. He stopped smoking 3 months ago. He has a history of hypertension, and well-controlled diabetes with oral hypoglycemic agents. He has no ulceration or gangrenous changes. A CTA was obtained and demonstrates right common iliac occlusion, diffuse right external iliac disease, severe common femoral stenosis with proximal profunda high-grade stenosis, and SFA occlusion. Your recommendation would be:
Aorto-bifemoral bypass with right fem-pop bypass
Right iliac angioplasty and stent, right femoral endarterecomy, and profundaplasty
Right fem-pop bypass
Right iliac angioplasty with stent and right fem-pop bypass
B
PVD & suggested intervention
- one level of disease =
- two levels of disease
- Tissue loss:
- claudication - medical management
- critical limb ischemia
- aorto-iliac and SFA
- SFA and infra-popliteal (tibial) - patients with tissue loss unless minor usually require complete revascularization
What are two types of open surgery for PVD
endarterectomy
bypass
What are three types of endovascular intervention for PVD
- angioplasty
- stent (with angioplasty)
- artherectomy
What 5 things determinates graft patency:
- Flow into the graft
- Run off (flow out of the graft)
- SFA and profunda > profunda
- 3 vessel > 2 vessel > 1 vessel (tibial) - Conduit
- Prosthetic above inguinal - ligament (large vessels, high flow)
- Vein below inguinal ligament
- Shorter > longer - Patient factors: Hypercoagulable state, Smoking
- Technical issues
Cause of early graft failure (retained valve, kinked graft, etc
what are the three different patencys
- Primary patency – graft patent without intervention
- Primary assisted patency - graft patent, but required intervention to maintain patency
- Secondary patency – graft occlusion but patency restored (thrombectomy, thrombolysis)
5 year patency rates:
**Aortobifemoral bypass: 80 – 90%
Axillary-femoral bypass: 40 – 85%
Femoral-femoral bypass: 40 – 83%
Femoral-above knee popliteal bypass: 60 – 75%
Femoral-below knee popliteal bypass: 60 – 70%
Femoral – tibial bypass: 50 – 60%
What are the trans-atlantic inter-society consensus classification of lesions? (4)
Type A lesions – Suitable for endovascular therapy
Type B lesions – Suitable for endovascular or open surgical revascularizaton
Type C lesions - Suitable for endovascular or open surgical revascularizaton
Type D lesions – Endovascular therapy has a prohibitive failure rate and should have open surgical revascularization
Know that there is a table of classification criteria for all of these
Which angioplasty?
- Wire passes in vessel wall behind the plaque
- Must have re-entry into the true lumen
- After angioplasty, requires stent placement
sub-intimal angioplasty
Which angioplasty?
1 Wire remains within the lumen, passes through the plaque
2. May require re-entry device
3. May not require stent after angioplasty
through lesion
Overall success rate of aorto-iliac angioplasty? (5 year)
60-83%
Infra-inguinal angioplasties (3 year)
Overall success rate of Fem-pop angioplasty (no stent)
with stent?
Infrpopliteal angioplasty:
33-51%
63-66%
62%
Overall, which intervention has the best survival rate?
81-97%
Aorto-bifemoral bypass
What are the four new endovascular treatment options
- Drug-eluting stent: Zilver PTX (Cook)
Paclitaxel - binds to microtubules in cells to inhibit mitosis
Local delivery
95% of total paclitaxel delivered within 24 hours
Sustained arterial wall levels through 56 days - Drug-coated balloon: Lutonix® (Bard)
PTA of lesion
Proprietary coating of paclitaxel to the balloon
Concentration of 2 μg/mm2 - Supera® stent (Abbott)
Braided nitinol
Deployed after PTA
Highly flexible, highly resistant to compression – can be used in popliteal - Bio-resorbable stents
A 52-year-old man is being referred to a vascular surgeon. He smokes 2 packs per day and has mild hypertension. The patient has been evaluated by a cardiologist and has a normal EF and no inducible ischemia. The patient complains of bilateral calf pain after walking 200 yards, consistent with calf claudication, and impotence. He works as a janitor and is beginning to have trouble doing his work. On exam, he has no palpable femoral pulses. He has no tissue loss. A CTA was obtained and demonstrates occlusion of the distal aorta and both common iliac arteries with reconstitution of the external iliac arteries and normal SFA, popliteal and tibial vessels. ABIs are 0.45 on the right and 0.48 on the left. The most appropriate plan would be:
Medical management – smoking cessation, exercise, antiplatelet
Aorto-bifemoral bypass graft
Bilateral external iliac angioplasty and stent placement
Ax-fem-fem bypass
a.
How do younger patients do with PVD interventions?
poorer outcomes and patency
What does smoking due to aorto-femoral graft patency at 5 yrs
in young patients
71% non smokers
77% stopped smoking
42% continue to smoke
An 82-year-old woman is brought to your office on a stretcher from the local nursing home. The patient has had progressive dementia for the past 5 years and currently is not oriented to person, place or time. Her daughter is with her and states that her mother no longer recognizes her. She is in your office because she has developed a large right heel lesion. On exam, the lesion measures 4 x 5 cm, has a foul odor with a loose eschar, but minimal surrounding erythema. X-ray shows obvious osteo. You are unable to palpate femoral or distal pulses. Your recommendation to the daughter is:
Angioplasty and stent for the suspected iliac occlusion
Long-term antibiotics (may require a PICC line)
Local debridement, culture, and tailor antibiotics to culture results
Above-knee amputation
D
What four reasons would there be to do an amputation instead of vascular intervention
Non-ambulatory patient
No further revascularization options
Advanced infection/gangrene (can be life-saving)
High-risk for surgical revascularization
When deciding which amputation to do
- must assess level of ____
- overall assessment of ___
- Better rehab potential with ____
- _____ is faster.
perfusion
patient
BKA
AKA
Non healing rates of BKA and AKA?
15%
5%
Peri-operative mortality rate of amputation?
30%
What percent are ambulatory with a BKA?
Increased energy requirement?
75%
30%
What percent are ambulatory with an AKA
increase in energy requirement?
39%
60%
What are the 1, 2, and 5 year survival rates in BKA?
80%
60%
38%
What are the 1, 2, and 5 year survival rates in AKA?
65%
44%
23%
What are the 5 predictive preop factors of non-independent living after amputation?
Age > 70 years (OR 4.0) Age 60-69 years (OR 2.7) Amputation level (OR 1.8) Homebound status (OR 1.6) Dementia OR (1.6)
What are the 7 predictive pre op factors for non-ambulatory status after amputation
Non-ambulatory (OR 9.5) AKA (OR 4.4) Age > 60 years (OR 2.7) Homebound, but ambulatory (OR 3.0) Dementia (OR 2.4) ESRD (OR 2.3) Coronary disease (OR 2.0)
Cost for revascularization/amputation:
Femoral-popliteal bypass:
Femoral-distal bypass:
Below-knee amputation:
$23,026 ± 1,117
$30,380 ± 1,349
$27,224 ± 2,896
Costs:
Fem-pop requiring revision
Fem-pop with amputation
Complicated BKA
28,700
42,200
40,600
PVD is common among ____
the elderly
_____ is a systemic disease with significantly decreased life expectancy
PVOD
Treat these four risk factors to reduce mortality
smoking
hypertension
diabetes
HLD
Invasive treatemnt is guided by _____ not by ____
patient symptoms, not “severity of the lesion”
