Peripheral Vascular Disease Flashcards
Susceptibility of stroke in the circle of willis
if on e of these vessels closes, there is enough vascular supply to maybe get away with not having a stroke
Most common access point (artery)
- common femoral
- usually right over the femoral head
- if you have any bleeding in the leg, a good place to stop it is over the femoral head
veins important in the development of varicose veins
- saphenous
- if they become dysfunctional, they can result in chronic venous insufficiency
most common cause of PAD
atherosclerosis
- coronary disease present in >50%
- mortality 2-3x greater vs general population
prevalence of PAD
3% 40-59yo
8% 60-69yo
19% >70yo
claudication vs pseudoclaudication
- claudication = pain in the calf or hip with walking that is relieved with rest
- pseudoclaudication = relieved when you have some support (i.e. resting on a shopping cart) whereas claudication is not
venous insufficiency stats
- 2x more prevalent than coronary heart disease and sx more prevalent than PAD
- 25 million have symptomatic reflux
- 5% seek treatment annually
- 2/3 of patients who seek treatment have saphenous reflux
- 72% of women and 42% of men will experience varicose veins by the time they reach their 60s
clinical issues from venous insufficiency
pain, swelling, varicose veins, skin changes, ulcers
pathophysiology of venous insufficiency
- normal veins have valves that open and close to assist return of blood to the heart
- in venous insufficiency, valves become damaged or diseased
- result of over-dilation of the venous vessels resulting in reflux
- in some cases, can also be caused by damaged or absent valves
how to assess if venous reflux is present
duplex ultrasound scan
risk factors for PAD
- Diabetes
- Smoking
- Hx of CAD
- Elevated cholesterol or decreased HDL
- HTN
- Sedentary
- Obesity
- male gender
- Age
- Recently, increased plasma homocysteine was recognized as maybe being important in pathogenesis of atherosclerosis
Risk factors of venous insufficiency
- Gender (women:men = 4:1; hormones may be a factor)
- Age
- Family hx
- Pregnancy
- Standing occupation
- Obesity
- Prior trauma or surgery
- Sedentary lifestyle/prolonged sitting
Sxs of venous insufficiency
- leg pain, aching, or cramping
- burning or itching of the skin
- leg or ankle swelling
- “heavy” feeling in legs
- skin discoloration or texture changes
- open wounds or sores
- restless legs
- varicose veins
atypical symptoms of PAD
- pain in the ankle with walking
- rest pain may manifest in only one toe
- back, hip and leg sxs in patients with chronic disc disease
- “fatigue in the calf” with walking
PAD: inspection
skin color, hair loss, skin necrosis or ulceration, edema, bulging veins
PAD: palpation
- feel for all pulses and grade them
- carotid, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial
arterial insufficiency ulcer
- aka ischemic ulcer
- dry and painful
venous stasis ulcer
-wet and painless
PAD: auscultation
- listen for carotid and femoral bruits
- abdominal bruits may indicate renal or mesenteric vascular stenosis
How to perform and calculate Ankle-Brachial Index
- detects arterial disease of the lower extremities
- patient restins supine 5-10 mins
- continuous wave, hand-held doppler
- measure systolic BP in both arms - the higher value is the DENOMINATOR of ABI
- measure systolic BP in DP and PT - the higher value is the NUMERATOR of ABI
- if there is a discrepancy between arms and the guy is old, you need to worry about subclavian stenosis
ABI values
- ratio >0.9 –> normal
- = 0.9 - >0.4 –> mild to moderate disease
- = 0.4 –> severe disease
- index is not always predictive of severity of sxs
- DOES NOT DETERMINE WHETHER THE PROCESS IS A STENOSIS OR OCCLUSION
diagnostic tests
- duplex ultrasound
- magnetic resonance angiography
- spiral CT scanning with contrast
duplex ultrasound
- combines ultrasound and doppler velocity measurement with color flow
- non invasive
- technologist dependent
- exercise testing
common place for clots to form
popliteal artery
digital subtraction angiography
- GOLD STANDARD FOR ANY ENDOVASCULAR INTERVENTION OR SURGERY
- invasive, requires intra-arterial access
- need iodinated contrast
- alternatives to contrast include carbon dioxide and gadolinium
why use radial artery
- provides nice access to the heart
- can stent coronary arteries etc. through the radial
- offers more safety than the femoral because there are two main arteries that supply the forearm (the femoral is the only one for the leg)
exercise training
- builds collaterals
- if you demand more blood flow, the blood vessels will work better
risk factor modification
- smoking cessation
- lipid lowering therapy
- diabetes control
- weight loss
- BP control
Drug therapy options
- cilostozol - improve walking distance (avoid in pts with poor LV function)
- Clopidogrel, efficen, or Brilinta - antiplatelet drugs
- statins - lipid lowering
treatment of venous disease
- compression stockings
- diuretics, weight loss
- wound care
- surgical stripping
- percutaneous ablation techniques
Main limitations of ABI
- calcified ankle vessels result in artificially “normal” ABI (DM, RF)
- normal ABI in patient with aortoiliac disease - only becomes abnormal with exercise testing
classification of PAD - Fontain’s stages vs Rutherford’s categories
Fontaine:
1: asymptomatic
2a: mild claudication
2b: moderate to severe claudication
3: ischemic rest pain
4: ulceration or gangrene
Rutherford:
0: asymptomatic
1: mild claudication
2: moderate claudication
3: severe claudication
4: ischemic rest pain
5: minor tissue loss
6: major tissue loss
endovascular intervention
- balloon angioplasty
- self-expanding and balloon-expandable stents
- atherectomy
- laser
- cryoplasty
- mechanical thrombectomy
- intraarterial thrombolytic therapy
- stent grafts
- aneurysm coiling/vascular embolization
Chronology of catheter-based device therapy
- 70-80s: balloon angioplasty
- 80-90s: directional atherectomy, variety of lasers (thermal, excimer, etc.)
- 90s-now: the stent era
