Peripheral Vascular Disease Flashcards
What is the most common underlying cause of peripheral arterial disease?
Atherosclerosis (narrowing of arterial lumen that reduces blood flow to limb)
What is the progression of peripheral arterial disease?
Asymptomatic stenosis
Chronic arterial insufficiency
Limb-threatening ischemia (can be sudden tho)
What is important to know about PAD and mortality?
PAD is a powerful, independent predictor of mortality
What are fatty streaks in atherosclerosis?
Thickened intima and accumulation of foam cells
Where do plaques commonly occur?
Bifurcations: aortic, iliac, femoral
Important risk factors for atherosclerosis/PAD
Hypertension, diabetes, dyslipidemia/hyperlipidemia, smoking
Acute vs chronic limb ischemia
Acute: sudden decrease in limb perfusion, potential threat to limb viability
Chronic: pts who present later than 2 wks after onset of acute event
Where do most pts with PAD have athersclerosis?
Lower extremity
Groups at risk for PAD
Over 70
50-69 with hx of smoking/diabetes
40-49 with diabetes and one other risk factor for atherosclerosis
Leg sxs: claudication or ischemia pain at rest
Known atherosclerosis at other sites
Diabetes and amputation
Dose-response relationship between HgbA1c level and risk of amputation
What is claudication?
Intermittent discomfort (cramps,aches) in defined muscle group, induced by exercise and relieved with rest Calf, thigh or buttock
What is Leriche syndrome?
Claudication (buttock, hip, thigh)
Absent/diminished femoral pulses
ED
What is the site of stenosis for each claudication sx? Buttock/hip Thigh Upper 2/3 calf Lower 1/3 calf Foot
Aortoiliac disease (Leriche) Aortoiliac disease/common femoral artery Superficial femoral artery Popliteal artery Tibial or peroneal artery
What is critical limb ischemia?
When blood flow is insufficient to meet demands at rest
Threatened limb!
73-95% limb loss or death at one yr without tx
Time sensitive!!!
Presentation of critical limb ischemia
Ischemia rest pain: pain in forefoot/toes aggravated by elevation and relieved by dependency
Non-healing wounds/ulcers
Skin discoloration/gangrene (pale elevated and red lower)
What is the ankle-brachial index?
Ratio of ankle SBP divided by highest brachial SBP
When do you perform the ankle brachial index?
Lower extremity exertional sxs
Risk factors for PAD
ABI
What is an arterial duplex doppler ultrasound?
Reflected sound wave frequency is used to determine velocity of blood flow
Can find the site and severity of vascular obstruction (% stenosis)
What is the gold standard for diagnosis of PAD?
Vascular imaging: contrast arteriography (angiogram)
What are the lifestyle modifications and risk factor reductions for PAD?
Antiplatelet therapy (ASA or Plavix) Smoking cessation Lipid lowering therapy (moderate dose statin) Control blood sugar and BP Weight management
Tx for claudication sxs of PAD
Supervised exercise (30-45 min 3xwk for 12 wks) Cilostazol (Pletal): phosphdiestase inhibitor, antiplatelet and vasodilator effects
What is the first line tx for revascularization of PAD?
Endovascular in critical limb ischemia
What are the endovascular interventional procedures?
Percutaneous transluminal angioplasty, stents, atherectomy
Most common bypass graft
Femoral-popliteal
What is the most common cause of acute arterial occlusion?
Thromboembolism (majority originate in heart)
Others (sudden thrombotic occlusion of narrowed segment, atheroembolic debris, arterial dissection)
Sxs of acute arterial occlusion
6 Ps (usually in this order too) Paresthesia Pain (located distal and progress proximal) Pallor Pulselessness Poikilothermia Paralysis
Management of acute arterial occlusion
Emergency surgical consult Anticoagulation with heparin Thrombolytics- intrarterial Thromectomy/ embolectomy Surgical bypass Amputation in 25-30%
Most common things seen chronic venous disease
Telangiectasias, varicose veins, chronic venous insufficiency
Higher in women than men
What causes chronic venous disease?
Venous hypertension (dysfunction of venous valves, obstruction to venous flow, failure of venous pump)
What veins are affected in chronic venous disease?
Usually superficial ones
Main presentation of chronic venous disease
May be asymptomatic but aching. heaviness or burning sensation that is worse with standing and relieved by elevation
What causes chronic venous insufficiency?
Valvular incompetence or result of DVT with residual damage to vein (recanalization after DVT)
Rigid and thick-walled veins
What are more advanced clinical signs of chronic venous insufficiency?
Significant edema, skin changes, ulcerations
What is hemosiderin staining?
Seen in chronic venous insufficiency
Pigmented byproduct of Hb
What is lipodermatosclerosis
Seen in chronic venous insufficiency
Inflammation of layer of fat under epidermis, subQ fibrosis and hardening of skin
Looks like champagne bottle
What can you find with venous duplex dopple u/s?
Valve insufficiency, chronic vein wall thickening, chronic thrombosis
What is the gold standard to diagnose chronic venous insufficiency?
Venography
What do you see in stasis dermatitis?
Erythema, inflammation, pruritus, scaling and vesicle formation (mostly medial ankle)
Use emollients, barrier creams or topical corticosteroid
Management of chronic venous disease
Exercise, weight loss, mechanical, compression therapy, wound care
Meds (diuretics for edema, abx), radiofrequency or lase, sclerotherapy for small surface veins, vein stripping or skin grafts
When is compression therapy contraindicated?
Moderate to severe PAD, cellulitis and acute DVT
What is the most common cause of aortic aneurysms?
Atherosclerosis
Also connective tissue disease (marfans, ehlers-danlos), infection, trauma
Common presentation of aortic disease
Severe, persistent chest pain, syncope, CVA-like sxs, altered mental status, paresthesia
Hypertensive usually, dimished or unequal peripheral pulses, horner’s syndrome
Test of choice for dx of aortic dissection
CT chest and abdomen (CXR can be used to show widened mediastinum but not test of choice)
First line treatment of aortic dissection
True emergency! Immediate control of BP with beta-blockers (labetalol)
Most common sxs of thoracic aortic aneurysm
Most are asymptomatic
May have back pain, dysnpea, stridor, edema in neck and arms, distended neck veins, hoarseness
Diagnostic test of choice for thoracic aortic aneurysm
CT scan (ONLY IF STABLE)
Most common site of abdominal aortic aneurysm
Infrarenal abdominal aorta
What can an AAA lead to?
Rupture or dissection, thromboembolism, compromised renal blood flow
When can you feel the AAA in 80% of pts?
Over 5 cm
Sxs of abdominal aortic rupture
Excruciating abdominal pain that radiates to back, pulsatile mass, tenderness, hypotension
What is the diagnostic study of choice for screening of AAA?
Abdominal u/s
CT scan is more reliable tho and should be used when the diameter is closer to 5.5 cm
What is the age you look at for screening for AAA?
65-75 (all current or past smokers or have relative with AAA)
Management of AAA
Risk factor modification, watchful waiting (routine u/s), refer to vascular specialist
What types of repair can you do for AAA?
Endovascular repair or open surgical resection
Sxs of carotid artery stenosis
TIAs
Focal neuro sxs (amaurosis fugax which is transient monocular blindness or contralateral weakness/numbness, dysarthria or aphasia)
What might you see on a PE in carotid artery stenosis?
Bruits, absent pupillary light response, arterial occlusion or ischemic damage to retina
What is a Hollenhorst plaque?
Cholesterol embolus in retinal vessel
What is the first test dx of carotid artery stenosis and what is the gold standard?
Carotid duplex u/s (very sensitive and specific)
Cerebral angiography is standard but rarely performed
What are some risk equivalents for coronary heart disease?
PAD or carotid artery stenosis
Tx for symptomatic carotid artery stenosis
Revascularization by carotid endarterectomy or carotid artery stenting
