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Cardiovascular > Peripheral Vascular Disease > Flashcards

Peripheral Vascular Disease Flashcards

1
Q

What are common areas of stenosis for PAD?

A

Aortoiliac, superficial femoral, tibial

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2
Q

Is it more common for PAD to present in both legs or only one?

A

More have both. But 40% of patients have in only one.

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3
Q

Think of ____ as _____ of the legs. You get leg pain on exertion that resolves with rest.

A

PAD, angina

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4
Q

Are the risk factors for PAD the same as atherosclerosis?

A

Yes

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5
Q

If you have PAD, are you more at risk for CV death?

A

Yes, about 6x increase risk

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6
Q

What are the symptoms of PAD?

A

Intermittent Claudication (limp)
Cramp, calf fatigue with exercise, resolves with rest.
Blood flow normal at rest, limited with exercise
No symptoms at rest, onset only with exercise.

If the disease progresses, patients can get–
Ischemic rest pain/ischemic ulcers (critical leg ischemia)
Pain in the distal foot or heel, worsened by leg elevation and improved by dependency.
Distal, painful ulcers on toes or heel.
Blood flow limited at rest and exercise.
Symptoms at rest and with exercise.

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7
Q

True or False: PAD is more from chronic occlusion than from plaque rupture

A

True

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8
Q

What are signs of PAD? (4 signs)

A
  1. Decreased or absent pulses
  2. Bruits (abdominal, femoral)
  3. Muscle atrophy
  4. In severe PAD (critical leg ischemia), pallor of feet with elevation and dependent rubor
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9
Q

Where do you palpate for posterior tibial artery?

A

behind medial malleolus

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10
Q

Where do you palpate for dorsalis pedis?

A

On top of the foot

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11
Q

What are the factors that affect arterial hemodynamics? (4 factors)

A
  1. Perfusion pressure
  2. Blood viscosity
  3. Arterial stenosis (radius and length. radius most important)
  4. Flow velocity (hemodynamic severity increases at higher flow velocities)
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12
Q

True or False: For flow velocity, the higher the velocity, the less narrowing it takes to cause a decrease in pressure and flow across a stenosis.

A

True

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13
Q

Even with laminar flow, when blood pressure increases, you get more _____ stress.

A

Shear stress

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14
Q

What does shear stress trigger in endothelial cells?

A

Dilation. from production of NO.

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15
Q

Collateral vessels may develop at sections of _____.

A

Stenosis

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16
Q

Do collateral vessels help much for bringing blood across stenotic lengths of vessel?

A

Not much. They are high resistance

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17
Q

What does endothelium distal to stenosis do?

A

Vasoconstrict, because of the turbulent flow and dropped pressure across stenosis.

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18
Q

What is Ankle-Brachial Index (ABI)?

A

Blood pressure measurement in the ankle right above the malleoli. Doppler probe detects the systolic blood pressure. You take the ratio between the systolic blood pressure in the ankle and the systolic blood pressure in the arm. In a healthy person, the systolic blood pressure should be about the same around your body. In a healthy person, the ankle is actually higher pressure than at the brachial artery.

Ratio less than 0.90 is considered abnormal

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19
Q

For the ABI, under what ratio is a positive finding for PAD?

A

0.90

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20
Q

For ABI, does a normal patient has a stronger systolic pressure at the brachial artery or posterior tibial?

A

Posterior tibial

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21
Q

What are implications for therapy in PAD? (name 3)

A
  1. Prevent CV events (MI, stroke, vascular death)
  2. Improve limb symptoms, exercise performance, and QOL
  3. Heal ulcers and prevent limb loss
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22
Q

What are treatments for PAD? (name 3)

A
  1. Surgery or angioplasty improves hemodynamics
  2. Exercise training improves muscle metabolism
  3. Drugs (cilostazol) have multiple mechanisms
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23
Q

What are aneurysms?

A

Pathological expansion of all 3 arterial layers

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24
Q

What is the normal aorta size in an adult? (at root, mid descending, and infra-renal)

A

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

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25
Q

What is the size for Abdominal Aorta Aneurysm?

A

> or = 3.0 cm or 50% increase in size relative to proximal normal segment

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26
Q

When you open up an aneurysm, what do you see?

A

A lot of atherosclerosis and thrombosis

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27
Q

What are the mechanisms of aneurysm formation? (name 4 and some physiological factors that cause them)

A
  1. Weakened aortic wall (decreased elastin and collagen)
  2. Inflammation (B and T lymphocytes, macrophages, cytokines, autoantigens)
  3. Proteolytic enzymes (Increased MMP, uPa, tPa. Decreased TIMP)
  4. Biomechanics stress (elastin disruption, turbulent blood flow, mural thrombus)
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28
Q

What is the incidence of AAA?

A

40-50 per 100,000 men and 7-12 per 100,000 women

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29
Q

How many people die annually in the U.S. from AAA?

A

16,000

30
Q

True or False: Ruptured aneurysms are the 13th leading cause of death in the USA.

A

True

31
Q

What are the 4 major risk factors of AAA?

A
  1. Age
  2. Gender
  3. Smoking
  4. Family history
32
Q

For AAA, what is the 5-year rupture rate % in relation to size? (give %s)

less than 4 cm
4-5
5-6
6-7
greater than 7 cm
A

Size - 5 year rupture rate

less than 4 -    2%
4-5 -    2-13%
5-6 -    25%
6-7 -    35%
7 cm -    75%
33
Q

At about what diameter do clinicians start to get concerned about AAA rupture?

A

5-6cm (25% 5 year rupture rate)

34
Q

For AAA, is fixing small aneurysms beneficial?

A

No. Studies show that managing them is more beneficial than fixing small AAA aneurysms.

35
Q

What are symptoms of AAA?

A

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

36
Q

How are AAAs typically discovered?

A

Physician physical examination (rarely) or incidental discovery from imaging for another indication

37
Q

Why is a symptom of AAA back abdominal discomfort or back pain?

A

Because AAA is retroperitoneal

38
Q

What are the best imaging tools for AAA?

A

CT and MRI

Ultrasound and X-rays can work but not as well. Angiography isn’t that good for this because it only images the lumen

39
Q

True or False: Imaging with CT for AAA is good for imaging and planning for intervention

A

True

40
Q

What is the surgical procedure for infrarenal AAA? (older way)

A
  1. Cross clamp aorta below the renal arteries, cross clamp the iliacs.
  2. Open up aneurysm and take out gunk
  3. Put in tube graft
  4. Overlay sac like thing
41
Q

What is the newer procedure for fixing infrarenal AAA?

A

Endovascular infrarenal aortic repair

Basically deploy catheters that open up stent like things. Can 3D print to customize fit to patient’s branch arteries

42
Q

How common is aortic dissection?

A

~30 cases / million / yr

43
Q

True or False: Aortic dissection can cause sudden death

A

True. 3-5% sudden deaths.

44
Q

For aortic dissection, what is the mortality rate if left untreated?

A

1%/hour mortality x 24 hours
75% mortality at 2 weeks
90% mortality at 3 months

45
Q

What are the 2 mechanisms of aortic dissection?

A
  1. Primary intimal rent/tear

2. Rupture of vasa vasorum (causing ingrowth)

46
Q

What are risk factors for aortic dissection? (name 8)

A
  1. HTN (drugs e.g. cocaine)
  2. Inherited disorders of CT (marfan syndrome, ehlers-danlos syndrome)
  3. Bicuspid aortic valve
  4. Coarctation (congenital aorta narrowing)
  5. Pregnancy
  6. Aortitis
  7. Iatrogenic (surgery, arterial catheterization)
  8. Trauma
47
Q

True or false : aortic dissections are often occlusive

A

True

48
Q

What is the symptom of aortic dissection?

A

Majority of cases present with severe, tearing pain

49
Q

Aortic dissection of different arteries leads to different clinical outcomes. Name 5 and the level of arterial dissection.

A
  1. Stroke (carotid)
  2. Syncope (vertebral)
  3. MI (coronary)
  4. Intestinal ischemia (mesenteric)
  5. Renal failure (renal arteries)
50
Q

What is the treatment for aortic dissection? Both medically and surgically

A

Medical-
Control DeltaPressure/DeltaTime (beta blockers)
Control BP (nitroprusside, ACEIs, CCB)
Control Pain (narcotic analgesia)

Surgical-
Endovascular grafts. Stents.

51
Q

True or False. In aortic dissection, the artery can unravel.

A

True

52
Q

What is the 3rd most common peripheral vascular disease?

A

Venous Thromboembolic Disease (VTE)

53
Q

What percentage of Venous Thromboembolic Disease (VTE) are asymptomatic or undiagnosed?

A

2/3 (66%)

54
Q

Venous Thromboembolic Disease (VTE) account for what percentage of hospital deaths?

A

5-10%

55
Q

Prophylaxis is important for preventing VTE. Without prophylaxis, what % of MI, paralytic stroke, and hip surgery patients develop VTE?

A

MI - 24%
Paralytic stroke - 60%
Hip surgery patients - 75%

56
Q

What percentage of PE deaths had not received any prophylaxis

A

58%

So, it’s important to treat prophylactically.

57
Q

Of patients with VTE, how many have post-phlebitic syndrome?

A

40-80%

58
Q

What is post-phlebitic syndrome?

A

It is when there is damage to venous valves after treatment of thrombosis. Causes swollen area that is tender and limits activities

59
Q

Where are the most common locations for acute venous thromboembolism?

A

Many are in legs or pelvis. Can result in pulmonary embolism

60
Q

What are the visible signs of chronic VTE?

A

Stage 1. Swelling
Stage 2. Visible collateral vessels
Stage 3. Stasis dermatitis
Stage 4. Ulceration

61
Q

What are the 3 points of virchow’s triad?

A
  1. Abnormal flow (stasis)
  2. Injury/Inflammation
  3. Coagulation factors

Typically takes more than one of these to result in thrombosis

62
Q

What is thrombophilia? (4 criteria)

A

Propensity to clot. Any alteration in coagulation balance that:

  1. Increases thrombin production
  2. enhances platelet activation/aggregation
  3. mediates endothelial activation/damage
  4. and/or mediates fibrinolytic inhibition
63
Q

What is the risk factor for severe inherited thrombophilia?

A

Homozygous protein C deficiency (rare)

64
Q

What is the risk factor for mild inherited thrombophilia?

A

Heterozygous Factor V Leiden (common)

65
Q

How is thrombophilia typically acquired?

A

Infection, inflammatory, and certain drugs (estrogens)

66
Q

What Xa inhibitors are preferred for treating venous thromboembolism?

A

Direct Factor Xa inhibitors (rivaroxaban, apixaban, edoxaban)

  • Oral
  • No cofactor needed (Reversible)
  • do not bind PF4 - no risk of HIT
  • Inhibit free factor Xa and factor Xa in prothrombinase complex–better attenuation of thrombin generation
67
Q

What are the 3 risk factors for VTE?

A
  1. Hyper coagulable states
  2. Venous Trauma
  3. Stasis
68
Q

What is the most pertinent chronic risk for VTE?

A

Post-phlebitic syndrome

69
Q

What is the most pertinent acute risk for VTE?

A

Acute venous and pulmonary thrombosis (morbidity)

70
Q

What is the treatment for VTE?

A

Anticoagulation

Cardiovascular (22 decks)

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