Vascular disorders (arterial) Flashcards
What PAD does this indicate:
Pain into thigh/buttocks/groin
ED
Weakness in legs when walking
Extreme limb fatigue
Pain relief with rest and starts again when walking
Leriche’s syndrome = claudication in buttock/thigh, impotence + decreased femoral pulse
aorta-iliac
What PAD does this indicate:
Intermittent claudication confined to thigh + upper ⅓ of calf
Dependent rubor of foot (improvement w/ lifting)
Atrophic changes in lower leg - loss of hair, thinning of skin/subcutaneous tissues, disuse atrophy of muscles
femoral + popliteal
What PAD does this indicate:
1st = Ischemic ulcer or foot gangrene (NO claudication)
Ischemic rest pain confined to dorsum of forefoot, lower calf (relieved with dependency/increased blood flow by gravity)
Does not occur w/ standing, sitting, or dangling
Severe + burning
Awaken from sleep (MC at NIGHT)
atrophic skin changes, non healing wounds
Tibial + pedal
What are risk factors for PAD?
> 70 years old or ~50 w/ risk factors (DM or tobacco use)
What PAD is most common in white men 50-60 who smoke cigarettes?
aorta-iliac
What PAD is most common in black and latino patients, from atherosclerosis ~1 decade after development?
femoral + popliteal
What PAD is most common in diabetic patients, extensive calcification, claudication may not be present?
tibial and pedal
What causes PAD?
atherosclerotic lesions in extremities
What is diagnostic for aorta-iliac + femoral-popliteal?
ABI<.9
What would this PE indicate
PE: Femoral pulses + distal pulses absent or weak with bruits of aorta, iliac, femoral
Dx: ABI <.9, exaggerated by exercise, CTA + MRA (only when symptoms require intervention)
aorta-iliac PAD
What would this PE indicate
PE: Common femoral pulsation normal, popliteal + pedal pulses reduced
Dx: ABI <.9 is diagnostic, <.4 = limb-threatening, duplex ultrasound, CTA and MRA (only if revascularization is planned, but must be monitored)
femoral-popliteal PAD
What would this PE indicate
PE: femoral + popliteal pulses may/may not be present, absent pedal pulses, dependent rubor w/ pallor on elevation, skin of foot - cool, atrophic, hairless
Dx: often ABI <.4, digital subtraction angiography is gold standard, MRA/CTA less helpful
NOT plantar surface burning + not relieved w/ leg dependency
tibial-pedal PAD
What is gold standard in tibial-pedal PAD diagnosis?
digital subtraction angiography
When should you admit an aorta-iliac PAD?
Evidence of chronic limb-threatening ischemia (resting pain + tissue loss)
Acute limb ischemia (needing IV anticoagulation + surgery)
When should you admit a femoral-popliteal PAD?
REFER IF - progressive symptoms, short-distance claudication, rest pain, ulceration
ADMIT IF: chronic limb threatening ischemia or foot infection
When should you admit a tibial-pedal PAD?
ADMIT IF: any patient w/ DM and foot ulcer + infection (emergent I&D) with broad spectrum abx
Lateral
arterial
Medial
venous insufficiency
What is the cornerstone of aorta-iliac PAD treatment?
cardiovascular risk reduction + exercise program
- smoking cessation
- weight loss
How do you treat aorta-iliac PAD?
- antiplatelet therapy (aspirin or clopidogrel)
- low dose rivaroxaban w/ aspirin
- high dose statin
- cilostazol (walking distance improvement)
- endovascular therapy (best for single stenosis)
What is a surgical intervention for aorta-iliac PAD?
Prosthetic aorta-femoral bypass graft (highly effective), graft from axillary artery, contralateral femoral artery graft
What’s first line for a femoral-popliteal PAD?
medical + exercise therapy, risk factor reduction
- antiplatelet therapy (aspirin or clopidogrel)
- low dose rivaroxaban w/ aspirin
- high dose statin
- cilostazol (walking distance improvement)
What’s general treatment for all PAD?
- antiplatelet therapy (aspirin or clopidogrel)
- low dose rivaroxaban w/ aspirin
- high dose statin
- cilostazol (walking distance improvement)
and lifestyle changes
When should you surgically intervene for a femoral-popliteal PAD?
Progressive claudication, incapacitating, interferes significantly w/ essential daily activities or if pain at rest or ulcers threaten foot
–>
Bypass surgery (femoral-popliteal using autologous saphenous vein)
What are alternative treatments for femoral-popliteal PAD??
Endovascular techniques – angioplasty + stenting in patients undergoing aggressive risk factor modification with smaller lesions
Thomboendarectomy to remove plaque
What’s first line treatment for tibial-pedal PAD?
Prevent ulcers, revascularization to avoid major amputation if ulcer appears + not healing
Bypass + endovascular techniques (saphenous vein)
Amputation
What is Leriche’s syndrome and what is it associated with it?
claudication in buttock/thigh, impotence + decreased femoral pulse
aorta-iliac PAD
What are the 6 Ps of acute arterial occlusion of a limb?
Pain
Pulseless
Pallor
Paresthesia
Paralysis
Poikilothermia
What are symptoms of acute arterial occlusion of a limb?
Sudden onset of extremity pain, loss or reduction in pulses, neurologic dysfunction, pallor, coolness, mottling
What could cause acute arterial occlusion of a limb?
History of claudication
A fib (MC)
What causes acute arterial occlusion of a limb?
Embolism or thrombosis of diseases atherosclerotic segment
>50% from heart → LE, 20% → cerebrum
Pre-existing CAD or PAD + claudication
What could this indicate:
PE: low capillary refill, decreased/absent pulses, cool temperature
acute arterial occlusion of a limb
What diagnostic methods are useful for acute arterial occlusion of a limb?
Duplex US is 1st imaging choice
Doppler + lab = little to no flow in vessels with myoglobinuria + metabolic acidosis
Consider CT angiography
How do you treat first line acute arterial occlusion of a limb?
Immediate revascularization + heparin