Peripheral Vascular Disease Cases (small group)

Question 1

What is intermittent claudication, and what disease causes claudication?

Answer 1

Intermittent claudication means to limp when walking (or pain, discomfort or tiredness in the legs that occurs during walking) that is relieved by rest and is typically due to peripheral artery disease

• peripheral artery disease = atherosclerotic occlusions in their arteries to the lower extremities
• Claudication is the symptom of skeletal muscle ischemia with exercise.

Question 2

How is ischemic rest pain different from claudication? What is the cause?

Answer 2

=An aching sensation in the distal foot and toes that occurs when the patient lies flat or elevates the leg (particularly at night in bed) not just during exercise

Cause: severe arterial disease where blood flow is not adequate to meet resting tissue metabolic needs

Question 3

What are the concerns with ischemic rest pain?

Treatment?

Answer 3

Patients with ischemic rest pain are at risk for tissue loss, due to ischemic ulceration, and gangrene (tissue necrosis).

Typically, surgery or angioplasty is required to restore blood flow and prevent limb loss.

Question 4

What could you expect to see in a patient that has PAD and stenosis in the iliac artery?

Answer 4

• Femoral bruits
• Diminished femoral pulse
• Absent pedal pulses

*A loss of laminar flow and kinetic energy causes the turbulence and pressure drop

Question 5

In a patient with PAD in the leg, why would their foot turn red and then blanch with elevation?

Answer 5

• Limitation in blood flow to distal limb
• So skin is chronically vasodilated which leads to blood pooling and venous engorgement when the leg is dependent.
• In contrast, when the leg is elevated there is insufficient arterial pressure and flow to overcome gravity, and the skin blanches because of lack of flow

Question 6

In a patient with left leg PAD, what BP changes (if any) would you expect to see in the following?

1. Left ankle
2. Right ankle

Answer 6

1. Decrease in BP: fixed obstruction and downstream vasodilation decreases BP
2. Increase in BP: Increased demand and systolic BP

Question 7

What is a duplex scan?

Is it enough to diagnose a DVT?

Answer 7

• Duplex: ultrasound + Doppler
• Duplex alone is generally adequate to diagnose leg DVT in most cases (but not DVT involving more proximal iliac veins).

Question 8

A patient comes into the ED for a provoked DVT. What medications would you give and for how long?

Answer 8

• Heparin in the hospital - 5 days
• Start on Warfarin day 1 and continue for 3-6 months
  
  • Shorter periods of warfarin therapy are associated with a high rate of recurrent DVT.

Question 9

Why would a patient get brown skin discoloration and ulceration on their ankle 2 years after a DVT?

Treatment?

Answer 9

1. The blood clot destroyed the venous valves
2. which resulted in increased venous pressure (particularly at the ankle) when standing, walking or running.
3. The increased venous hydrostatic pressure caused extravasation of plasma proteins and red cells into the interstitial space.
4. Hemoglobin deposited from the red cells produces the brownish discoloration at the ankle.

Treatment: compression socks

Question 10

What is abnormal about this ECG?

Answer 10

• The key findings are Q waves and ST elevations in anterior leads (V1-V4) . The ST elevations are a current of injury and the Q waves are evidence of infarction.
• If these findings are new this is an ACUTE ANTERIOR MYOCARDIAL INFARCT or ST ELEVATION MI (STEMI).
• In most acute cases of this type the ST elevations will resolve over time but the Q waves will remain.