Treatment of Peripheral Vascular Disease

Question 1

• 84 year-old female with acute right-sided weakness and paresthesias
• Word finding difficulties and some short-term memory loss
• History of atrial fibrillation
• Off warfarin and off aspirin for 10 days prior to colonoscopy
• MRI showed several left parietal infarcts indicating left hemisphere stroke
• Duplex – 70-99% stenosis left internal carotid artery

What could have caused her stroke?

Answer 1

Cardiac embolus from absence of anticoagulation for atrial fibrillation

Could also be athero-embolism from carotid

Question 2

What are next steps in management?

a. Resume warfarin alone
b. Bridge with heparin and start warfarin
c. Resume aspirin
d. Medical therapy plus pursue carotid revascularization

Answer 2

b & d

Bridge with heparin and start warfarin

Then do carotid endarterectomy (open and clean carotid)

Question 3

A couple months later, she still has problems. What findings does the ultrasound show?

Answer 3

Turbulence at the carotid bifurcation from stenosis

Question 4

What’s the main purpose of carotid stenting?

Answer 4

To prevent embolic stroke

Question 5

73 year-old female has systemic atherosclerotic disease. Now with uncontrolled hypertension even though she’s taking 4 antihypertensives (diuretic, spironolactone, CCB). She had acute renal failure when getting started on ACEI.

What could be the cause of her hypertension?

Answer 5

Hypertension from renal artery stenosis

Question 6

You send her to the cath lab and find severe stenosis in the left renal artery. What do you do now?

Answer 6

Do a renal artery stent

Question 7

• 65 year-old male with atherosclerosis and medium-vessel vasculitis
• Presents with postprandial abdominal pain x 2 weeks
• No pain if he doesn’t eat
• Starting to avoid meals
• 8-lb weight loss

What could causing his abdominal pain/ weight loss? What do you do?

Answer 7

Stenosis of superior mesenteric artery –> intestinal ischemia

*After eating you shunt blood to your intestines, not enough supply for blood demand (abdominal angina)

*Put a stent in the superior mesenteric artery

Question 8

• 38 year-old male with history of aortic valve replacement with mechanical aortic valve
• Anticoagulation (warfarin) held 10 days for elective surgery
• Restarted warfarin without heparin bridge
• 2 days after starting back on warfarin developed left calf discomfort walking short distances
• Left foot discomfort when sleeping at night, better if foot is hanging over side of bed

What is wrong with him? Why?

How would you treat him

Answer 8

• Stopping warfarin for elective treatment caused him to be in a hypercoagualable state
• Sent thrombus from aortic valve into left popliteal artery causing acute limb ischemia (absent pulses)
• Could use heparin and revascularization therapy (remove clot put in a stent)