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Clin Med I Final Review > Peripheral Vascular Disease > Flashcards

Peripheral Vascular Disease Flashcards

1
Q

Narrowing of arterial lumen —> reduced blood flow to limb

A

Peripheral Arterial Disease (PAD)

Usually atherosclerotic

Inc risk of CV/Cerebrovascular events (stroke, MI, death)

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2
Q

Continuum of PAD

A

Asymptomatic stenosis
Chronic arterial insufficiency
Limb-threatening ischemia

Leading cause of M&M for US adults

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3
Q

Atherosclerosis frequently occurs at:

A

Bifurcations - aortic, iliac, femoral

More than 85% of adults > 50 have some

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4
Q

Major contributing factors for atherosclerosis

A

HTN
DM
Dyslipidemia
Smoking

Endothelial dysfunction
Inflammatory factors
Immunologic factors
Plaque rupture

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5
Q

Acute v chronic limb ischemia

A

Acute: SUDDEN decrease in limb perfusion, potential threat to limb

Chronic: patients who present later than 2 weeks after onset of acute event

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6
Q

High risk groups for PAD

A

Age ≥ 70
Age 50-69 with Hx of smoking or DM
Age 40-49 with DM and at least one other risk factor
Leg symptoms: claudication or ischemic pain at rest
Known atherosclerosis at other sites

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7
Q

Intermittent discomfort (cramping, aching) in defined muscle group, induced by exercise and relieved with rest

A

Claudication

Common in calf, thigh, or buttock

Due to insufficient blood flow to meet activity demands

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8
Q

Location of claudication and site of stenosis

A

Buttock/hip —> Aortoiliac
Thigh —> Aortoiliac or common femoral artery
Upper 2/3 of calf —> Superficial femoral artery *** Most common
Lower 1/3 of calf —> Popliteal artery
Foot —> Tibial or peroneal artery

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9
Q

Leriche Syndrome

A

“ACE”
Absent/dismissed femoral pulses
Claudication (buttock, hip, thigh)
Erectile dysfunction

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10
Q

Ischemic rest pain

A

Pain in forefoot/toes AGGRAVATED by ELEVATION, relieved by dependency
Non-healing wounds/ulcers
Skin discoloration/gangrene
Pale when elevated, redness when lowered

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11
Q

Physical findings in PAD

A 
Color changes
• Pallor with elevation, dependent rubor (redness)
Thin, dry, shiny, hairless skin
Brittle hypertrophic ridged nails
Ulcers
Necrosis

Cool to touch, delayed cap refill

Diminished/absent pulses (use handheld Doppler)

Auscultation for bruits

CV assessment (thorough)

Extremity neuro assessment

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12
Q

Ankle-Brachial Index (ABI)

A

Ratio of the ankle systolic BP divided by highest brachial systolic BP

ABI ≤ 0.9 with exertional symptoms is diagnostic for PAD

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13
Q

Vascular testing in ASYMPTOMATIC PAD

A

If abnormal or absent pedal pulses, OR
Age ≥ 70 OR
Age 50-69 with Hx of smoking/DM
—> perform ABI

ABI ≤0.9 diagnostic for PAD
ABI 0.91-1.3 = normal
ABI > 1.3 = not PAD but do workup because likely another problem

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14
Q

Arterial duplex Doppler ultrasound

A

Reflected sound wave frequency is used to determine velocity of blood flow

Accurate, noninvasive, inexpensive

Findings: site and severity of vascular obstruction (%)

Can also be used to asses stent/graft latency

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15
Q

Technically the gold standard for PAD

A

Vascular imaging - contrast arteriography

• Use prior to intervention and for ongoing surveillance

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16
Q

PAD Management

A 
***Control risk factors and manage Sx
Antiplatelet therapy: Aspirin or clopidogrel (Plavix)
Smoking cessation
Lipid lowering therapy regardless of LDL
Control of blood sugar and BP
Weight management

For claudication Sx:
Supervised exercise program (30-45 min ≥ 3x/week for 12 weeks)

17
Q

PAD Revascularization

A 
Endovascular = first line
• Percutaneous transluminal angioplasty
• Stents
• Atherectomy
Surgical
• Bypass graft (femoral-popliteal = most common, using saphenous vein)

Indications:
Critical limb ischemia
Significant or disabling symptoms unresponsive to lifestyle/pharm therapy

18
Q

Compartment Syndrom

A

Complication of revascularization procedures
Tissue swells from repercussion —> increased compartment pressures —> nerves, veins, arteries compressed

Sx: pain out of proportion, pain with passive stretch, paresthesia

Clinical Dx

Management: Immediate surgical consultation (fasciotomy with delayed closure)

19
Q

The 6 P’s of Acute Arterial Occlusion

A

Paresthesia
Pain (Located dismally, progresses proximally)
Pallor
Pulselessness (severely diminished or absent)
Poikilothermia - cool nails
Paralysis

20
Q

Management of Acute Arterial Occlusion

A 
Emergency surgical consultation
Anticoagulation: Heparin
Thrombolytic therapy - intrarterial
Thrombectomy/embolectomy
Surgical bypass of obstruction
Amputation in 25-30%, long-term survival is poor
21
Q

Risk factors for Chronic Venous Disease

A 
Age
Obesity
Smoking
Hx of lower extremity trauma
Hx of VTE
Pregnancy
Family Hx of venous disease
Standing occupation
22
Q

Predominant cause of chronic venous disease is

A

Dysfunction of venous valves —> venous hypertension
Failure of the venous pump

Flow is directly abnormally from deep to superficial system —> local tissue inflammation, fibrosis, and ulceration

23
Q

Sx of chronic venous disease

A 
(May be asymptomatic)
*Aching, heaviness, or burning sensation, worse with standing, relieved by elevation
Swelling
VIsible varicosities
Restless legs
Skin hyperpigmentation
Ulceration
Telangiectasias/reticular veins
Stasis dermatitis
Edema
24
Q

Less common signs of Venous insufficiency that look cool

A

Hemosiderin staining - from pigmented byproduct of hemoglobin

Lipodermatosclerosis - inflammation of layer of fat under the epidermis subcutaneous fibrosis and hardening of skin
• Gross swelling with fibrous band around ankle

25
Q

Classic but rarely needed gold standard for Dx of venous insufficiency

A

Venography

Invasive, expensive

26
Q

Stasis Dermatitis

A

Commonly on medial ankle
Skin changes: erythema, inflammation, pruritis, scaling, and vehicle formation
Diagnosis is usually clinical
Typically respond to dermatological agents (emollients, barrier creams, topical corticosteroids)

27
Q

Management of chronic venous disease

A

Exercise (walking, ankle flexion)
Weigh loss
Elevate legs 30 min 3-4x/day to decrease edema
Compression therapy (20-30 mmHg pressure
• Contraindicated in moderate to severe PAD, cellulitis and acute DVT so confirm Dx

28
Q

Unsnap Boot

A

Zinc paste impregnated bandage for wound care in venous ulceration

29
Q

Medications for chronic venous disease

A

Diuretics to reduce edema if already on one for other conditions)

Abx for secondary infections (look for lymphangitis)

Radio frequency or laser (non surgical ablative methods)

Sclerotherapy for small surface veins

Surgical: vein stripping if significant, skin grafting for ulcers

30
Q

Etiology of Aortic Aneurysms

A

Atherosclerosis = most common

Connective tissue disease
• Marfan’s syndrome, Ehlers-Danlos syndrome

Infection

Trauma (pseudoaneurysms)

31
Q

Type A vs Type B aortic dissections

A

Type A: involves arch proximal to left subclavian artery (worse prognosis)

Type B: proximal descending thoracic aorta (usually just beyond left subclavian)

32
Q

Clinical presentation of aortic dissection

A

Severe, persistent chest pain (sudden, radiates to back)
Syncope
CVA-like symptoms (hemiplegia, hemiparesis)
Altered mental status
Paresthesia of extremities
Usually hypertensive if conscious (can be hypo if in shock)
Dismissed or unequal peripheral pulses
Neuro deficits

HORNER’S SYNDROME - ptosis, mitosis, anhidrosis

33
Q

Diagnostic studies for aortic dissection

A

CT Chest and Abdomen = test of choice

CXR may show widened mediastinum

34
Q

Management of aortic dissection

A

EMERGENCY

Immediate control of BP (decrease SBP to 100-120 and pulse pressure)
• Beta-blockers are first line

Urgent surgical intervention (all Type A and +/- Type B)

35
Q

Abdominal aortic rupture

A

Associated with high mortality (~50% exsanguinate before reaching hospital, only 50% who get surgery survive)

Sx:
Excrutiating abdominal pain that radiates to the back
Pulsatile abdominal mass
Tenderness
Hypotension

Dx: Abdominal ultrasound = study of choice (can also do CT if >5.5cm)

36
Q

Carotid artery stenosis

A

May result in cerebral infarction

Sx:
Transient ischemic attacks
Focal neurological Sx
• Amaurosis fugax- transient monocular blindness
•Contralateral weakness/numbness of extremity or face

Physical exam:
Carotid bruit
Absent pupillary light response
Fundoscopic exam - arterial occlusion or ischemic damage to retina

Dx: Carotid duplex ultrasound performed first (sensitive/specific), cerebral angiography is gold standard but rarely performed

Tx: If asymptomatic, controversial; with Sx, revascularization (CEA)

Clin Med I Final Review (5 decks)

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