Peripheral Vascular Disorders

Question 0

What are the 5 common Risk Factors for PAD?

Answer 0

1) Family Hx
2) Age > 70 yrs old
3) Obesity
4) Smoking
5) Preexisting Health Conditions - CAD, diabetes, HTN, dyslipidemia, clotting disorders, hyperhomcysteinemia.

Question 1

What are the SxS associated with Peripheral Arterial Disease (PAD)?

Answer 1

1) Structural - Hair loss distal to occlusion, thick and op ague nails, shiny and dry skin and muscle atrophy.
2) Color Changes - Elevational pallor and dependent rubor.
3) Pulse - diminished or absent pulses distal to occlusion, cool extremities.
4) Sensation Changes - Paresthesia, numbness and tingling.
5) Ulceration/Gangrene
6) Edema - Although usually absent, may be present and related to dependency.

Question 2

What is Homocysteine? How is it related to PAD? How is it treated?

Answer 2

1) Homocysteine is a protein that promotes coagulation
2) Elevated Homocysteine levels are associated with genetic factors and a diet low in folic acid, Vit B6 and Vit B12.
3) Tx includes Vit B6 and Vit B12, which often lowers Homocysteine levels.

Question 3

What is the hallmark symptom for PAD in the lower extremity?

Answer 3

Intermittent Claudication - Pain that occurs with activity and is relieved with rest. Caused by inability of the ARTERIAL system to provide blood flow with increased demand.

Question 4

Define Rubor

Answer 4

Rubor a reddish-blue coloring of the skin that occurs when the extremity is placed in a dependent position after it has been elevated. This color change suggests severe PAD, in which vessels cannot constrict and remain dilated.

Question 5

What are the Pharmacological treatment used in patients with Intermittent Claudication?

Answer 5

1) Cilostazol - A phosphodiesterase III inhibitor that is a vasodilator and also interferes with platelet aggregation.
2) Aspirin and Clopidogrel are anti platelet drugs indicated for the prevention of cardiovascular ischemic events in patients with IC but not for treatment of it.

Question 6

What is the main difference between grafts used to bypass occluded vessels below the knee and those above the knees?

Answer 6

Grafts below the knee require a native vessel (i.e., autologous, the patients own vein) to ensure patency; however, synthetic grafts may be used for bypass procedures on larger vessels above the knee.

Question 7

What is the reasoning behind teaching patients with PAD to avoid temperature extremities?

Answer 7

Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery.
Cold temperature causes vasoconstriction, which decreases perfusion to the extremities.

Question 8

Why is the patient with PAD taught to avoid stress and also crossing their legs?

Answer 8

1) Emotional upsets cause vasoconstriction by stimulating the SNS.
2) Crossing of the legs is avoided to prevent vessel compression.

Question 9

Describe Subclavian Steal Syndrome

Answer 9

Subclavian Steal Syndrome occurs when there is diminished flow to the arm from the subclavian artery due to stenosis, there will be a preferential reverse flow down the vertebral artery to the arm when the arm is being used.

Question 10

What are the 3 Inflammatory Disorders, mentioned in Pellico, that cause cause ⬇ peripheral arterial circulation?

Answer 10

1) Takayasu’s Arteritis
2) Bechet’s Disease
3) Giant Cell Arteritis

Question 11

Describe Raynaud’s Disease Vs Raynaud’s Phenomenon.

Answer 11

Raynaud’s Disease refers to vasospasm that occurs with cold or stress.
Patients with Scleroderma or SLE may have the same Sxs. This is called Raynaud’s Phenomemon

Question 12

What are the SxS of Raynauds Disease in the order that they occur?

Answer 12

The patients skin becomes cyanotic due to vasospasm, then vasodilation causes rubor, then numbness tingling and burning pain occur.

Question 13

What are the Tx available for patients with Raynaud’s Disease?

Answer 13

1) Avoid stimuli i.e., cold or tobacco.
2) CCBs may be given to relieve some symptoms
3) Sympathectomy - Interrupting the sympathetic nerves

Question 14

What is Buerger’s Disease (aka Thromboangiitis Obliterans)? What are the SxS and how is it treated?

Answer 14

1) Buerger’s Disease is an autoimmune disease characterized by recurring inflammation of the intermediate and small arteries and vein, resulting in thrombus formation and vessel occlusion. It is usually caused by smoking.
2) SxS include pain that is bilateral and symmetric with focal lesions.
3) Tx includes sympathetic block to dilate vessel and increase blood flow. Smoking cessation as well.

Question 15

What is an Aneurysm? What are the 2 different types?

Answer 15

An Aneurysm is a localized out-pouching, sac or dilation formed at a weak point in the artery wall.

1) Saccular Aneurysm - Projects from one side of the vessel only.
2) Fusiform Aneurysm - Occurs when the entire arterial segment becomes dilated.

Question 16

What is a Mycotic Aneurysm?

Answer 16

Small aneurysms due to localized infections.

Question 17

What are the 5 Risk Factors for Aneurysms?

Answer 17

1) 50 yrs and older
2) Male
3) Tobacco use
4) Family Hx
5) HTN

Question 18

What are the 2 most important diagnostic indications of an AAA and how is an AAA diagnosed?

Answer 18

1) A pulsatile mass in the abdomen and a systolic bruit heard over the mass.
2) Duplex ultrasonography or CT is used to determine the size, length, and location of the aneurysm.

Question 19

Which class of meds are used to treat a stable AAA?

Answer 19

Antihypertensives - i.e., ACEIs, ARBs, CCBs, BBs, and diuretics.

Question 20

What are the SxS of a Thoracic Aortic Aneurysm?

Answer 20

1) Pain - usually constant but may occur when PT is supine
2) Brassy cough, hoarseness, Stridor, or aphonia (loss of voice)
3) Dysphagia (difficulty swallowing) from pressure of aneurysm pressing on esophagus.
4) Dyspnea (from pressure of aneurysm pressing on airways)
5) Unequal Pupils from pressure against the cervical sympathetic chain.

Question 21

How is a Thoracic Aortic Aneurysm usually Diagnosed?

Answer 21

TEE or CT

Question 22

What is an Endoleak?

Answer 22

An Endoleak is a complication of endovascular graft surgery. It is a persistent leaking of blood out of the graft and into the aneurysm sac.

Question 23

What is a Dissecting Aneurysm?

Answer 23

A Dissecting Aneurysm occurs when a tear develops in the intima or the media of the aorta, resulting in a dissection.

Question 24

What are the 3 main causes of a Dissecting Aneurysm?

Answer 24

1) HTN
2) Blunt force chest trauma
3) Cocaine use

Question 25

(T/F) The patient who has had endovascular repair must lay supine and be on bed rest post operatively.

Answer 25

True

Question 26

Upper extremity venous thrombosis is not as common as LEVT, what are the causes of UEVT?

Answer 26

1) IV catheters
2) Hypercoagulation disorders
3) Effort Thrombosis - caused by repetitive motions, usually from playing sports.

Question 27

What is Virchow’s Triad?

Answer 27

Virchow’s Triad are the 3 components that are thought to contribute to venous thrombosis:

1) Stasis of Blood
2) Vessel Wall Injury
3) Altered Coagulation

Question 28

(T/F) Venous Thrombosis is associated the affected limb being warmer than the unaffected limb and the affected limb having edema.

Answer 28

True

Question 29

Which patients are at increased risk for developing DVTs?

Answer 29

1) PTs with a Hx of varicose veins, hypercoagulation, neoplasticism disease, CVD, or recent surgery or trauma.
2) Obese, immobile or old patients
3) Women taking oral contraceptives

Question 30

(T/F) A negative D-dimer decreases the the likelihood of a DVT.

Answer 30

True - D-dimer blood assay is marker of coagulation activity, such as in the presence of a DVT or PE.

Question 31

What is the half-life of Heparin? What is the significance of this?

Answer 31

Heparin has a half-life of about 1 hour, therefore in an emergency, heparin is discontinued for a period of at least an hour.

Question 32

What is the normal PTT range and the therapeutic range for patients on Heparin?

Answer 32

1) Normal PTT is 21 to 35 sec
2) Therapeutic PTT is 1.5 to 2.5 times normal range or 33 to 85 seconds.
* A PTT greater than 100 secs puts the patient at significant risk for hemorrhage.

Question 33

What are some of the advantages of LMWH over Unfractionated Heparin?

Answer 33

1) Can be given safely to renal patients and pregnant women

2) Fewer bleeding complications and ⬇ chance of HIT

Question 34

What is the difference in the MOA between Heparin and Thrombolytics?

Answer 34

Heparin is an anticoagulant and will not dissolve an existing clot, while thrombolytics will dissolve existing clots (most effective when given in the first 3 days of acute thrombosis).

Question 35

Which symptom is usually the the first sign of excessive anticoagulant dosing?

Answer 35

Bleeding- Especially from the kidneys, seen as microscopic amounts of blood in the urine.

Question 36

Which drug is used as an antidote for heparin and what are its 2 main side effects?

Answer 36

Protamine Sulfate - Side effects include bradycardia and hypotension.

Question 37

How are the effects of Warfarin reversed?

Answer 37

1) Vitamin K
2) FFP
3) Prothrombin concentrate

Question 38

Which 2 drugs are used in the Tx of HIT?

Answer 38

1) Lepirudin

2) Agatroban

Question 39

Define Varicose Veins

Answer 39

Varicose Veins are abnormally dilated, torturous, superficial veins caused by incompetent venous valves.

Question 40

Describe the difference between Primary and Secondary Varicose Veins.

Answer 40

1) Primary - Without involvement of deep veins

2) Secondary - Resulting from obstruction of deep veins

Question 41

What are the 2 methods used to diagnose Varicose Veins?

Answer 41

1) Duplex Scan

2) Air Plethysmograph

Question 42

Describe the Ankle-Brachial Index (ABI).

Answer 42

ABI is calculated by dividing the ankle pressure by the higher of the two brachial pressure.

1) Normal ABI - Greater than or equal to 1.0
2) Asymptomatic obstructive disease - 0.9 to 1.0
3) Claudication - 0.5 to 0.9
4) Rest Pain or Sever arterial disease - Less than 0.5

Question 43

What are the major characteristics of an Arterial Ulcer?

Answer 43

1) Usually located over bony prominences on toes and feet
2) Dry and can lead to gangrene
3) Punched out looking appearance
4) Pale yellow wound bed