02.20 Peripheral Arterial Occlusive Disease Flashcards Preview

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Flashcards in 02.20 Peripheral Arterial Occlusive Disease Deck (56):
1

Atherosclerotic occlusive disease of the arterial system distal to the aortic bifurcation

PAD

2

Atherosclerosis commonly occurs in:

Aortic cusps
Branches of the aorta (subclavian and carotid)
Bifurcations (aorta to iliac artery, iliac artery to the superficial and deep femoral, anterior tibial to peroneal and posterior tibial artery, lumbar and iliac arteries

3

Progression of atherosclerosis

Initial lesion
Fatty streak
Intermediate lesion forms
Atheroma develops
Fibroatheroma
Complicated lesion

4

Histologically normal
Macrophage infiltration in sites of inflammation
Isolated foam cells

Inital lesion

5

Intima of the vessel becomes thickened because of intracellular lipid accumulation

Fatty streak

6

Due to intracellular lipid accumulation and small extracellular lipid pools

Intermediate lesion forms

7

Mixture of lipid intracellular accumulations core of extracellular lipid
Stage where disease may already become overt, presenting with clinical symptoms

Atheroma develops

8

Fibrotic or calcific layers

Fibroatheroma

9

Because the intima is no longer smooth, there are hematoma-hemorrhages and some degree of thrombosis

Complicated lesion

10

How lesions cause symptom

Stenosis/occlusion
Embolism

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Symptoms appear if _____

Collateral circulation is poor
Artery occludes acutely

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Leg attack
pain is felt in large muscle groups distal to an arterial lesion after exercise

Intermittent claudication

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Severe compromise of arterial flow
Failure of compensatory mechanisms
Exacerbated by elevation
Limb threatening

Ischemic rest pain

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Tissue necrosis occurs when blood flow is inadequate to maintain tissue viability even at rest

Gangrene

15

RF for atherosclerosis

Tobacco use
Diet
DM
Hyperlipidemia
HPN
Fam Hx

16

Important things to elicit in Hx

Cardiopulmonary assessment
Neurological assessment
Renal assessment

17

Specific vascular evaluation

Inspection of skin changes
Capillary refill
Auscultate for bruits in central vessels
Pulse examination
Pulse grading

18

Absence of pulse

0/4

19

Weak (may suggest impairment)
Effort must be made to search for the pulse

1/4

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Normal

2/4

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Full

3/4

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Bounding (may suggest aneurysm or calcification)

4/4

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Classification of PAD based on the Fontaine

I - asymptomatic
IIa - mild claudication
IIb - moderate to severe claudication
III - ischemic rest pain
IV - ulceration or gangrene

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Classification of PAD based on Rutherford

00 - asymptomatic
I1 - mild claudication
I2 - moderate claudication
I3 - severe claudication
II4 - ischemic rest pain
III5 - minor tissue loss
III6 - major tissue loss

25

To confirm diagnosis
To establish patient baselines
Assess RF of the patient

Non-invasive vascular testing

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Non-invasive vascular testing

ABI
Doppler/Duplex waveform analysis
Segmented pressure and waveform studies

27

Normal ABI value

1 to a little over 1

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Reflect the degree stenosis

Waveforms

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Sources of error in noninvasive vascular testing

Wrong cuff width
Incompressible arteries
Operator/technician factors

30

Not used solely fro diagnosis, but is generally reserved for treatment planning

Invasive complex imaging

31

General complications of invasive complex imaging

Contrast reactions
Arterial complciations
Thrombosis
Atheroembolism
Puncture site complications

32

Reserved for cases when there's a plan for intervention since it's already an invasive procedure

Conventional angiography

33

Complications of conventional angiography

Hemorrhages or pseudo-aneursym formation at site of needle insertion
Too invasive

34

Still need IV needle and contrast
Can produce a 2D or #d picture

CT angiography

35

Risks/complications of CT angiographyh

Dye-induced nephrotoxicity
Dye allergy
Thrombosis
Atheroembolism
Puncture-site

36

Risk of MR angiography

Presence of any metallic objects in the body is CI

37

Invasive complex imaging

Convetional arteriography
CT angiography
MR angiography

38

Most important risk factor modification

Cessation of tobacco use

39

Overall strategy in treatment of critical limb ischemia

Relieve ischemic pain
Heal ischemic ulcers
Improve patient functionality and quality of life
Prolong survival

40

Primary outcome of treating CLI

Amputation-free survival

41

Common profile of CLI patients you will encounter

Elderly
Multiple co-morbidities
Non-ambulant/non-functional leg

42

Medical treatment

Cilostazol
Pentoxphylline

43

In patients with limb threat

Revascularization

44

Revascularization procedure

Percutaneous endovascular intervention
Surgical revascularization
Medical vascularization

45

Percutaneous endovascular intervention

Angioplasty
Atherectomy
Stenting

46

Surgical revascularization

Enderarterectomy
Bypass surgery

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Indications for surgical management

Gangrene
Pain at rest
Non-healing arterial ulcer
Disabling claudication

48

Gold standard
Established long-term patencies, lim salvage and mortality outcomes

Operative bypass
Open surgical revascularization

49

First line teratment
Minimally invasive, more tolerated by sick patients

Angioplasty
Stenting

50

Minimally invasive endovascular techqnies for infra-inguinal disease

Percutaneous angioplasty
PTA with stenting
Atherectomy
Subintimal angioplasty
Percutaneous endografting

51

Intermediate-term outcome of angioplasty, when used preferentially for critical ischemia in anatomically suitable patients, provides very acceptable limb salvage and survival despite a relatively high stenosis rate

Primary angioplasty for critical limb ischemia

52

Use of VEGF and basic FGF to promote collaterall circulation growth

Medical revascularization

53

Single stenosis < 1 cm in length
Endovascular treatment
Endovascular

TASC-A

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Multiple stenosis focal, each < 1 cm in length
Endovascular therapy is the preferred treatment even in long lesions or tandem lesions
Endovascular therapy is preferred treatment

TASC-B

55

Stenoses 1-4 cm in length
Short occlusions < 2cm in length
Surgery

TASC-C

56

Diffuse long stenosis < 4 cm in length
Occlusions > 2cm in length
Surgery

TASC-D