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ECOS III Final > Vascular Assessment > Flashcards

Vascular Assessment Flashcards

1
Q

What is PAD?

A

Stenosis or occlusion in the aorta or arteries of the limbs

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2
Q

What causes PAD?

A

Atherosclerosis (most common), thrombosis, embolism, vasculitis

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3
Q

What are the RF for PAD?

A

Smoking, DM, HTN, HLD

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4
Q

Which vessels can are affected in PAD?

A

Abd aorta, iliac artery, femoral A, popliteal A, tibial A, peroneal A, less commonly UE arteries

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5
Q

Where do lesions occur in PAD?

A

At arterial branch points due to increased turbulence, altered shear stress and intimal injury

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6
Q

What are the findings in the history of someone with PAD?

A

Can be asymptomatic initially, intermittent claudication, location of sx depends on vessels affected, critical limb ischemia, acute limb ischemia

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7
Q

What is intermittent claudication?

A

Pain/ache/cramp in muscles that occurs with exercise and relieved with rest;
Reliable reproduced with set walking distance;
Not exacerbated by changes in position

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8
Q

What is critical limb ischemia?

A

Rest pain occurs in severe PAD when resting blood flow cannot accommodate nutritional needs of tissues;
Pts may wake up with pain when legs are horizontal –> put legs in dependent position to improve blood flow and sx;
May also present with non-healing ulcers and gangrene;
Requires urgent attention and revascularization (but not necessarily emergent bc collateral vessels provide circulation)

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9
Q

What is acute limb ischemia?

A

Sudden, rapid decrease in limb perfusion;
Presents with cold, painful, pale limb with absent pulses, weakness, and reduced sensation;
Causes = thrombosis of LE artery, stent or bypass or graft, embolism;
Medical emergency (skeletal muscle only tolerates ischemia for 4-6 hours)

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10
Q

What are the PE findings for mild PAD?

A

Decreased or absent pulses and muscle atrophy

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11
Q

What are the PE findings for moderate PAD?

A

hair loss, smooth shiny skin, thickened nails

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12
Q

What are the PE findings for severe PAD (critical limb ischemia)?

A

Non healing ulcers or gangrene, ischemic neuropathy, pallor when legs elevated, rubor when legs dependent (reactive hyperemia)

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13
Q

What are the features of arterial insufficiency ulcers?

A

Location: over toe joints, medial and lateral malleoli, anterior shin;
Appearance: well demarcated dry punched out, can have necrotic eschar;
Pulses: absent;
Pain: severe;
Foot temp: warm or cool;
Surrounding skin: shiny, taut, loss of hair

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14
Q

What are the features of venous stasis ulcers?

A

Location: medial and lateral malleoli, posterior calf;
Appearance: irregular border, pink base covered with yellow fibrinous tissue, wet, exudate common, can be large;
Pulses: present;
Pain: mild to moderate;
Foot temp: warm;
Surrounding skin: peripheral edema, stasis dermatitis

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15
Q

What is venous insufficiency?

A

Consequence of incompetent veins –> venous HTN + extravasation of fluid and blood into tissue;
Can be primary (structural abnormality in vein wall or incompetent valve) or secondary (valves incompetent due to prior DVT)

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16
Q

What is the presentation for venous insufficiency?

A

Varicose veins, leg swelling (worse with prolonged standing), skin changes (stasis dermatitis, lipodermatosclerosis) and ulceration

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17
Q

What is carotid artery stenosis?

A

due to atherosclerosis affecting carotid artery, most commonly occurs at carotid bifurcation due to turbulent flow

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18
Q

What is carotid artery stenosis?

A

due to atherosclerosis affecting carotid artery, most commonly occurs at carotid bifurcation due to turbulent flow

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19
Q

What are the RF for carotid artery stenosis?

A

Age >65, HTN, HLD, DM, smoking, personal or family hx of CVD

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20
Q

What is the presentation for carotid artery stenosis?

A

Can be asymptomatic (incidental finding on brain imaging or carotid bruit found on exam –> confirm with imaging);
Symptomatic can cause TIA and stroke (can be due to thrombosis, embolism, low flow state through tight lesion)

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21
Q

What are the sx associated with TIA/stroke affecting the middle cerebral artery (MCA)?

A

Contralateral hemiplegia, contralateral hemisensory loss, aphasia (dominant hemisphere), neglect (non-dominant hemisphere)

22
Q

What are the sx associated with TIA/stroke affecting the ophthalmic artery?

A

Ipsilateral carotid stenosis can cause amarosis fugax (recurrent transient monocular blindness; shade coming down effect)

23
Q

What are the PE findings for carotid stenosis?

A

carotid bruit

24
Q

What is important to rule out if a pt has bilateral chronic LE edema?

A

CHF, nephrotic syndrome, cirrhosis

25
Q

What procedures or imaging should be done to further evaluate PAD?

A

ABI and/or CT angiogram or MR angiogram

26
Q

What is the first line test for PAD?

A

ABIs (ankle blood pressure/arm BP)

27
Q

Which ABI values indicate PAD?

A

Mild PAD = 0.70-.90;
Moderate PAD = 0.40-0.69;
Severe PAD = <0.40

28
Q

What is a normal ABI value?

A

1.0-1.4

29
Q

What should be done if a pt has an ABI value above 1.4?

A

Inconclusive for PAD so additional tests need such as toe-brachial index or exercise ABIs

30
Q

When would a CT angiogram or MR angiogram be performed in a pt with PAD?

A

Not first line test and may be performed to help with surgical planning

31
Q

Is imaging needed for chronic venous insufficiency?

A

Primary a clinical diagnosis and if there is enough evidence on exam, may not need further studies; however if diagnosis unclear can use venous duplex US to help confirm

32
Q

What is the recommendation for screening for asymptomatic carotid stenosis?

A

Screening is not recommended

33
Q

Who should be tested for carotid artery stenosis?

A

Bruit identified on exam, stroke or TIA in vascular distribution that could be attributed to carotid stenosis

34
Q

What are not good indications for carotid imaging?

A

Vague dizziness or hx of syncope without focal neurologic deficits

35
Q

What is the workup for transient vision loss?

A

Ophthalmologic evaluation, carotid artery imaging (US, MR angiogram, CT angiogram), ESR and CRP (if clinical concern for giant cell arteritis), echocardiogram and holter monitor (if initial workup unrevealing and clinical concern persists for embolic TIA)

36
Q

What risk factor modification should be recommended for PAD pts?

A

smoking cessation

37
Q

What is the primary prevention for PAD?

A

If pt doesn’t have ASCVD, start statin therapy to prevent it from occurring

38
Q

What secondary prevention should be done for pts with ASCVD/PAD?

A

Prevent progression of disease + delay onset of disease manifestations;
all pts should get a high intensity statin regardless of LDL levels

39
Q

What other medications can be given for secondary prevention of ASCVD/PAD?

A

BP control for pts with HTN; anti-platelet therapy (aspirin or clopidogrel)

40
Q

What is the tx for intermittent claudication?

A

Supervised exercise and/or pharmacologic therapy with cilostazol (avoid in CHF)

41
Q

What are the options for surgical treatment in PAD?

A

Revascularization, balloon angioplasty/stenting, bypass grafting

42
Q

What are the indications for revascularization?

A

Disabling or progressive sx of claudication despite medical therapy; pts with critical or acute limb ischemia

43
Q

What is the tx for acute limb ischemia?

A

Start systemic anticoagulation immediately, evaluate limb viability (if limb is viable options include endovascular thrombolysis or surgical revascularization)

44
Q

What are the tx basics for venous insufficiency?

A

Supportive measures (elevate legs, avoid prolonged standing, foot pump exercises, weight loss) + external compression stockings (varicose veins present us 20-30mmHg, deep venous insufficiency use 30-40)

45
Q

What medications can be provided for venous insufficiency pts?

A

Diuretics (must balance risk of AKI and volume depletion);
Topical corticosteroids (may treat inflammation associated with stasis dermatitis);
Moisturizers (for dry skin associated with venous stasis dermatitis)

46
Q

What are the tx options for venous stasis ulcers?

A

Ulcer debridement (key to remove necrotic tissue to help wounds heal) + wound dressings (low adherent absorbent dressing that takes up exudates while maintaining moist environment)

47
Q

What are the surgical tx options for venous insufficiency?

A

Thermal ablation (performed with either laser or radio frequency ablation), sclerotherapy (injection of chemical into vein causing fibrosis/occlusion), surgical interventions (vein stripping)

48
Q

What is the medical tx for carotid stenosis?

A

Anti-platelet therapy, statins, BP control, smoking cessation

49
Q

What is the surgical tx for carotid stenosis?

A

Carotid endarterectomy or carotid stenting (decision to do surgery depends on risk/benefit calculation)

50
Q

When should surgery be performed over medical tx in those with carotid stenosis?

A

Symptomatic carotid stenosis is >70% and pt life expectancy >5 years

51
Q

When may carotid stenting be preferable?

A

Carotid lesion not suitable for surgical access, head/neck radiation induced stenosis, other medical comorbidities that make surgery high risk

ECOS III Final (14 decks)

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