Vascular Disorders

Question 1

What is peripheral vascular disease of the lower extremities?

Answer 1

Decreased patency of the arterial supply to the lower extremities leading to claudication, ischemia and potentially limb loss

Question 2

What is atherosclerosis?

Answer 2

Thickening and hardening of arteries

Question 3

What is plaque?

Answer 3

Plaque may partially or totally block the blood’s flow through an artery
- Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood
- Over time, plaque hardens and narrows arteries

Question 4

What happens when plaque occurs in atherosclerosis?

Answer 4

1. Hemorrhage into the plaque
2. Plaque ruptures and a blood clot (thrombus) forms on surface
   - Affects large and medium-sized arteries

Question 5

How can plaque form from damage to the arterial wall?

Answer 5

by:
1. High levels of cholesterol and triglyceride in the blood
2. High blood pressure
3. Tobacco smoke
- Cellular debris will adhere to plaques (cholesterol etc.)
- Endothelium becomes thick and the diameter of the artery is reduced

Question 6

Complications of atheroslerosis?

Answer 6

1. Heart attack = ↓ blood supply to heart
2. Stroke = ↓ blood supply to brain
3. Gangrene = ↓ blood supply to arms and legs

Question 7

Etiology of PVD?

Answer 7

1. Vasculitis
2. Buerger’s Disease (Thromboangiitis obliterans)
3. Extrinsic compression (neoplasm)

Question 8

Buergers disease?

Answer 8

• affects younger or middle age cigarette smokers
• It is characterized by narrowing or occlusion of arteries and veins of extremities
  Rx – cessation of smoking

Question 9

Takayasu arteritis?

Answer 9

Systemic inflammation characterized damage to the large and medium arteries and branches
e.g. Aortic arch, brachiocephalic trunk
- Rx - NSAID

Question 10

Pathophysiology of PVD?

Answer 10

Narrowing of the lumen of the arterial supply to the lower extremity leads to decreased blood flow

Decreased blood flow → Decreased O2 supply → Anaerobic metabolism → Increased Lactic Acid → Pain with increased muscle use

Question 11

Tissues become ischemic as a result of decreased blood flow leading to?

Answer 11

1. pain at rest
2. poor wound healing
3. painful ulceration

Question 12

Consequences of disease progression?

Answer 12

As disease progresses patients are sometimes unable to ambulate and gangrene may set in with eventual need for amputation

Question 13

What is gangrene?

Answer 13

dead tissue caused by an infection or lack of blood flow
- occurs in the extremities of skin
e.g. toes, fingers and limbs

Question 14

Gangrene risk factors?

Answer 14

1. Hypertension
2. Cigarette smoking
3. Diabetics or overweight
4. Sedentary lifestyle
5. Hyperlipidemia
6. Increased age
7. History of other atherosclerotic disease (coronary artery disease or carotid stenosis)

Question 15

What is wet gangrene?

Answer 15

dead tissue that has been infected by bacteria
e.g. gangrenous diabetic foot

Question 16

Clinical presentation of wet gangrene?

Answer 16

1. claudication
2. ischemic rest pain
3. ischemic ulceration

Question 17

Clinical presentation of claudication?

Answer 17

Claudication requires a sustained walk
1. cramping/burning muscular pain
2. localized to a muscle group
e.g. buttocks, hips, calves, thighs, feet
3. reproducible
4. relieved with rest
5. no symptoms with standing
- Distribution of pain may suggest anatomic location of disease

Question 18

Clinical presentation of pseudo claudication?

Answer 18

1. cramping/burning and tightness muscular pain
2. localized to single muscle group buttocks, hips, calves, thighs or feet
3. not induced by exercise
4. distance to symptoms is variable
5. symptoms when standing
6. relief when position is changed

Question 18

Clinical presentation of Ischemic rest pain?

Answer 18

Deep bone pain in toes at rest
May or may not be relieved by dependency
Indicative of limb threat

Question 19

Clinical presentation of Ischemic ulcertaion?

Answer 19

ulcer on toes/between toes/dorsum of foot
localized skin necrosis
often noticed after trauma with persistent wound that will not heal

Question 20

What is toe gangrene?

Answer 20

Blackened toe/s
often foul smelling
indicative of dead tissue
limb at extreme risk

Question 21

Things to note in physical exam in PVD?

Answer 21

1. Pulse exam
2. skin
3. ankle brachial index

Question 22

Pulse exam in PVD?

Answer 22

Palpable vs. non-palpable
Audible by Doppler vs. not audible
Compare limbs
Pulse exam helps define level of disease
May also examine pulses after exercise
Skin

Question 23

Skin on examination in PVD?

Answer 23

Thin, brittle, shiny with thick opaque toes
Often cool
No toe hair
Poor capillary refill

Question 24

Ankle/Brachial index in PVD?

Answer 24

Ratio of Systolic Blood Pressure Ankle: Arm Normal ratio >1.0 Claudication 0.8-1.0 Ischemic Rest Pain <0.8 Results may be skewed by diabetes

Question 25

Imaging done in PVD?

Answer 25

Arteriography Duplex Ultrasound Magnetic Resonance

Question 26

Arteriography?

Answer 26

Advantages Gold standard for demonstrating anatomy of disease Provides therapeutic opportunities: Disadvantages Invasive: risk of hemorrhage, aneurysm, infection Contrast load is nephrotoxic

Question 27

Duplex ultrasound?

Answer 27

Advantages Noninvasive Fast/cheap Few complications Disadvantages Dependent on ultrasonographers ability Poor visualization below the knee

Question 28

Magnetic resonance?

Answer 28

Advantages Good resolution Allows visualization of surrounding structures Noninvasive with few complications Disadvantages Efficacy has not been demonstrated Cost/availability

Question 29

Treatment of claudication?

Answer 29

STOP SMOKING Exercise program Control diabetes, lower cholesterol 75% improve with non-operative management

Question 30

Treatment for Ischemic rest pain/ulcer/gangrene?

Answer 30

Must first determine how patient uses limb Angioplasty vs. Revascularization Gangrene or blackened toes require amputation but revascularization may preserve level and use of limb.

Question 31

Diagnosis of acute ischemia?

Answer 31

Rapid onset Pain Pallor No pulse Numbness or paralysis - the cold foot

Question 32

Therapy for acute ischemia?

Answer 32

1. Angioplasty to disrupt thrombus - using a balloon to stretch open a narrowed or blocked artery 2. Surgery to reestablish vascular integrity 3. Thrombolysis with or without surgery - Eminase (anistreplase) Retavase (reteplase) Streptase (streptokinase, kabikinase) 4. embolectomy 5. Anticoagulation to assist in blood thinning 6. Amputation if all of the above options fail

Question 33

Name venous diseases?

Answer 33

1. Venous Insufficiency - Varicose veins - Ulceration 2. Lower Extremity Deep Vein Thrombosis - Pulmonary embolism 3. Upper Extremity Deep Vein Thrombosis

Question 34

What is deep pain thrombosis?

Answer 34

occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs.

Question 35

Risk factors for DVT?

Answer 35

Major injury. Minor injuries — one not requiring surgery, a plaster cast, hospitalization, or extended bed rest at home for at least four days). Intravenous drug use — Direct trauma, irritation, and infection may be responsible for the high incidence of DVT noted in young drug users who inject these agents directly into their femoral veins Pregnancy — Pregnancy is associated with an increased risk of thrombosis that may be due in part to obstruction of venous return by the enlarged uterus, as well as the hypercoagulable state associated with pregnancy. Past history