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Cardiorespiratory > Lecture 15: PAD > Flashcards

Lecture 15: PAD Flashcards

1
Q

what is the atherosclerosis?

A

–The formation of lipid, cholesterol, and/or calcium-laden plaques within the tunica intima of the arterial wall, which can restrict blood flow. Rupture can cause intraluminal thrombosis that results in myocardial infarction, unstable angina, and/or ischemic stroke.

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2
Q

in what blood vessel layer the lipid material accumulates in atherosclerosis?

1) Tunica intimia
2) tunica media
3) adventitia

A

Tunica intima, subintima

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3
Q

what are the common sites (in order of frequency) of atherosclerosis?

A
  • -Abdominal aorta
  • -Coronary arteries
  • -Popliteal arteries
  • -Carotid arteries
  • -Atherosclerotic diseases
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4
Q

what is PAD?

A

A chronic condition characterized by the luminal narrowing of noncoronary peripheral arteries due to atherosclerotic plaques. Typically used to describe lower extremity PAD, but arteries of the bowel, kidneys, or brain can also be involved. Limb PAD can be asymptomatic or cause intermittent claudication, rest pain, or ischemic ulcers.

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5
Q

Does atherosclerosis cause acute or chronic symptoms?

A

canc ause both

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6
Q

what are the 3 causes of PAD?

A
  • -occlusive disorders (acute and chronic)
  • -aneurysmal disorders
  • -vasculitic disorders
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7
Q

what is the epidemiology of PAD?

A

1) Prevalence: 8.5 million in the US
- -Prevalence increases with age, starting from the age of 40
- -US incidence rates are highest among African Americans, followed by Hispanics, who are at a slightly higher risk than non-Hispanic whites.
2) Peak incidence: 60–80 years of age
3) Sex: ♂ = ♀

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8
Q

at what age PAD is at its peak?

A
  • -60–80 years of age
  • -Patients over the age of 40 may develop PAD if risk factors are present; over the age of 80 the probability of developing PAD is high even in the absence of risk factors.
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9
Q

what are the PAD risk factors?

A
  • -Older age
  • -HTN
  • -Smoking
  • -Diabetes
  • -Hypercholesterolemia
  • -Ethnicity
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10
Q

Prevalence rates of PAD are higher in African Americans than non-Hispanic whites. T/F

A

True

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11
Q

what is the clinical presentation of PAD?

A
  • -Claudication and atypical lower extremity pain
  • -Rest pain
  • -Ulceration
  • -Gangrene
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12
Q

is intermittent claudication sensitive to PAD?

A
  • -Intermittent claudication is a specific but not sensitive finding for PAD. Up to 40–50% of patients with PAD have atypical leg pain.
  • -Atypical lower extremity pain may be more common than claudication due to comorbidities, physical inactivity, and alterations in pain perception.
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13
Q

what is intermittent claudication?

A
  • -Pain, cramps, or paresthesia distal to arterial occlusion
    1) Femoropopliteal disease (most common) → calf claudication
    2) Aortoiliac disease (Leriche syndrome)
  • -Level of the aortic bifurcation or bilateral occlusion of the iliac arteries
  • -Triad of bilateral buttock, hip, or thigh claudication, erectile dysfunction, and absent/diminished femoral pulses
    3) Tibiofibular disease→ foot claudication
  • -Worsens upon exertion , completely relieved by rest or lowering affected limbs
  • -Reproducible when the patient is asked to walk the same distance as when he/she was symptomatic
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14
Q

what is the rest pain?

A

Rest pain is a continuous burning pain of the lower leg or feet. It begins, or is aggravated, after reclining or elevating the limb and is relieved by sitting or standing.

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15
Q

rest pain indicates…

A
  • -Rest pain occurs as the disease progresses and indicates severe ischemia.
  • -Typically in distal metatarsals
  • -Worse at night
  • -Improved when hanging feet over bed or standing
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16
Q

what is the ulcer?

A

An ulcer is a breach of the continuity of the skin, epithelium or mucous membrane caused by sloughing out of inflamed necrotic tissue.

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17
Q

what are the features of arterial ulcers?

A
  • -Punched-out appearance
  • -Intensely painful
  • -Grey or yellow fibrotic base and undermining skin margins
  • -Pulses are not palpable
  • -Most common on distal ends of limbs
  • -Can have associated skin changes- shiny skin, absence of hair
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18
Q

what are the common locations of arterial ulcers?

A

Usually involves the foot, particularly pressure points (e.g., lateral malleolus, tips of the toes)

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19
Q

what is the gangrene?

A

Gangrene is a type of tissue death caused by a lack of blood supply

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20
Q

dry vs wet gangrene?

A

Tissue necrosis (tissue death) that usually occurs as a result of inadequate blood perfusion. Inadequate arterial perfusion (e.g., in peripheral artery disease) results in sharply demarcated gangrene with dry/mummified necrotic tissue (dry gangrene). Gangrene due to bacterial infection or venous obstruction results in poorly demarcated, exudative gangrene that spreads rapidly and is associated with systemic infection (wet gangrene)

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21
Q

dry gangrene is a type of liquefactive necrosis.True/False

A

False
–Dry gangrene is a from of coagulative necrosis that develops in ischaemic tissue where blood supply is inadequate to keep tissue viable.

–The affected part is dry, shrunken and dark reddish-black. This usually brings about complete separation, with eventual falling off of the gangrene if not removed surgically- a process known as autoamputation

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22
Q

wet gangrene is a type of liquefactive necrosis. T/F

A

True

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23
Q

what factors influence management decisions in PAD?

A

1) Nature of Symptoms
- -Ischaemia V Non-Critical Ischaemia
- -Risk to Life or Limb
2) Patient’s General State of Health
3) Social Circumstances
- -Independence
- -Quality of Life

24
Q

what is the management of dry gangrene?

A
  • -For patients with dry gangrene without cellulitis, the limb should be revascularised first. The wound dressing is protective, reducing the risk for trauma or infection. The wound should be lightly wrapped with a bulky dry gauze bandage, avoiding excess pressure that could aggravate ischemia.
  • -Following revascularization, the wound should be monitored closely for signs of healing or for tissue necrosis/drainage that may indicate need for further debridement.
25
Q

how PAD is diagnosed?

A

–History & Examination
–Ankle Brachial Index (ABI)
–ABI following exercise testing
–Duplex ultrasonography is commonly used in conjunction with the ABI to identify the location and severity of arterial obstruction
–Radiology: angiogram
1)CT angiography
2)MRAngiogram
(usually reserved for patients where uncertainty remains following noninvasive testing or intervention is anticipated)

26
Q

what is the first-line diagnostic test for PAD?

A

ABI

27
Q

what is the ABI?

A

The ratio of systolic ankle blood pressure (BP) to systolic brachial BP. This is a fast, easy, and inexpensive way to screen for peripheral arterial disease (PAD). Normal ABI is 0.9–1.3; values below 0.9 indicate PAD, values above 1.3 indicate a noncompressible calcified vessel.

  • -0.40– 0.90 = mild to moderate PAD → claudication
  • -< 0.40 = severe PAD → resting pain, gangrene (critical limb ischemia)
28
Q

does vascular imaging is necessarily required for diagnosis?

A

No

  • -it is useful to determine the site and severity of arterial stenosis or occlusion (especially preoperatively and postoperatively)
  • -Color-coded duplex ultrasonography
  • -Digital subtraction angiography (DSA): the gold standard
  • -CT angiography
  • -MR angiography
  • -Oscillography
29
Q

ABI measurements in diabetic or older patients may be inaccurate because of Monckeberg sclerosis. T/F

A

True
A form of arteriosclerosis characterized by calcification of the intima and media that do not cause arterial stenosis. It is associated with diabetes mellitus and usually affects arteries in the extremities.

30
Q

rest pain occurs at what ABI level?

A

<0.5

31
Q

what is the management of PAD?

A
  • -The management of patients with lower extremity PAD is aimed at relieving symptoms and lowering the risk of cardiovascular disease progression and complications.
  • -The treatment of symptomatic lower is based on a careful assessment of risk factors, medical comorbidities, compliance with pharmacological treatments and follow up care.
  • -Patients with ischaemic pain or ulceration may require early intervention for limb salvage.
32
Q

what are the measures of risk factor modification?

A
  • -Antiplatelet therapy
  • -Smoking cessation
  • -Lipid-lowering therapy
  • -Treatment of hypertension
  • -Glycemic control
  • -Diet and exercise
33
Q

what are the conservative management options in PAD?

A
  • -Smoking cessation!
  • -Supervised graded exercise therapy
  • -Foot care (especially in diabetic patients)
  • -Avoid cold temperatures
34
Q

what is the supervised graded exercise therapy

A

The patient walks to the point of claudication, then continues for another cycle after a short rest. Recommended for 30–40 minutes 3–5 times a week.

35
Q

what is the treatment of symptomatic PAD?

A
  • -The initial treatment for exertional limb pain is a supervised exercise program.
  • -The addition of the phosphodiesterase inhibitor Cilostazol may also improve symptoms.
  • -With intensive medical management (risk factor reduction, exercise therapy, pharmacologic therapy) less than 5% or patients with claudication will develop any signs of limb-threatening ischemia.
36
Q

what is the cilostazol?

A

A phosphodiesterase inhibitor that inhibits platelet aggregation and acts as a direct arterial vasodilator. Used to alleviate the symptoms of intermittent claudication.

  • -Phosphodiesterase 3 (PDE3) inhibition → increased cAMP → increased activity of protein kinase A → reduced platelet aggregation
  • -Myosin light chain kinase inhibition → vascular smooth muscle relaxation → arterial vasodilation
37
Q

what are the indications of cilostazol?

A
  • -It is indicated in patients with lifestyle-limiting intermittent claudication only after 3 months of supervised graded exercise therapy.
  • -It is administered as a therapeutic trial for 3–6 months.
38
Q

what medications are used for medical therapy of PAD?

A

1) Antiplatelet therapy reduces morbidity and mortality
- -Aspirin: irreversible cyclooxygenase inhibition → decreased thromboxane A2 synthesis → decreased platelet aggregation
- -ADP receptor inhibitors
* Clopidogrel: inhibition of the P2Y12 ADP receptor → decreased platelet activation and platelet-fibrin crosslinking
* Ticagrelor: reversible inhibition of the P2Y12 ADP receptor (otherwise identical downstream effects as clopidogrel)
2) Lipid-lowering agent (usually statins)
3) Antihypertensive treatment
4) Hyperglycemia control

39
Q

what are the surgical management options in PAD?

A 
--Endovascular
percutaneous angioplasty
stents
--Reconstructive Vascular Surgery
--Amputation
40
Q

what are the indications for revascularization?

A
  • -Critical limb ischemia
  • -Failure of conservative and pharmacologic treatment
  • -Inability to perform normal work or activities because of claudication
  • -No limitations to exercise by other disease (e.g., chronic heart failure) if claudication is improved
  • -Anatomy of the lesion allows low-risk and long-term success of intervention
41
Q

what is the percutaneous transluminal angioplasty (PTA)?

A

A revascularization procedure in which a catheter with a balloon at its tip is passed along a guide wire to the site of arterial stenosis. The balloon is then inflated to relieve the obstruction. In patients with CAD or PAD, angioplasty is the preferred revascularization procedure for focal arterial occlusion or if patients are not surgically fit to undergo a bypass procedure.

42
Q

Lower Limb IschaemiaManagement?

A

–Careful Individual Patient Assessment
–Multi-disciplinary Approach
–Appropriate & Timely Interventions
–Avoid Amputation
Primary Amputation sometimes appropriate

43
Q

what are the causes of acute limb ischemia?

A 
1)Thrombosis
	Atherosclerosis, Bypass graft occlusion, Popliteal aneurysm
2)Embolic: 
	80% A Fib, 10% MI, 10% Aneurysm
3)Trauma / Iatrogenic
44
Q

what are the 6 P’s of acute limb ischemia?

A
  • -Pain
  • -Pallor
  • -Pulseless
  • -Paraesthesia
  • -Perishing cold (poikilothermia)
  • -Paralysis
45
Q

what is the differential diagnosis of acute limb ischemia?

A

Chronic Ischemia, Dissection, Vasospastic Disorders, Phlegmesia alba dolens, CHF, Meningococcal septicaemia

46
Q

what is the treatment of acute limb ischemia?

A
  • -Based on etiology/severity of ischemia / predicted outcome
  • -Resuscitation / Heparinization
  • -Open Surgical – Thromboembolectomy / Bypass
  • -Thrombolysis
  • -Other Endovascular Options
47
Q

how embolectomy is done?

A

–inflow
–Pass Fogarty balloon
–Check:
Back-bleeding
Completion angio
Doppler

48
Q

what are the trophic changes seen in PAD?

A
  • -↓ Skin temperature
  • -↓ Perspiration
  • -↓ Hair on legs
  • -Brittle nails, ↓ nail growth
  • -Atrophied muscles
  • -Dry atrophic, shiny skin and/or bluish skin discoloration
  • -Skin pallor when limb is elevated and reactive hyperemia of dependency → Buerger test for examination
  • -Livedo reticularis (advanced disease)
  • -Gangrene, ulcers, necrosis (end-stage disease): see also “Arterial ulcer”
49
Q

what is the critical limb ischemia?

A

1) The presence of any one of the following:
- -Resting pain
- -Ulcer
- -Tissue loss (gangrene)
2) Indicative of limb-threatening arterial occlusion

50
Q

what is the prognosis of PAD?

A
  • -Intermittent claudication → good prognosis
  • -Rest pain and/or ischemic ulcers → poor prognosis
  • -Increased cardiovascular mortality → high risk for secondary MI or stroke
51
Q

what is the compartment syndrome?

A

A surgical emergency in which increased pressure within a muscle compartment leads to impaired tissue perfusion. Most commonly affects the lower legs but can also occur in other parts of the upper and lower limbs and the abdomen. Presents with rapidly progressive pain and paresthesia, and without treatment, eventually motor deficits, absent pulses, pallor, and poikilothermia. Diagnosis is confirmed via measurement of compartment pressures.

52
Q

how PAD leads to acute limb ischemia?

A

Rupture of an atherosclerotic plaque or thrombosis in a diseased arterial segment can cause acute limb ischemia in a patient with peripheral arterial disease.

53
Q

what is the best initial test for acute limb ischemia?

A

1) Best initial test: arterial and venous Doppler
- -Diminished or absent Doppler flow signal distal to site of occlusion.
2) Confirmatory test: angiography (DSA, CTA, MRA)
- -Digital subtraction angiography (DSA) is the imaging modality of choice.
- -Should only be performed if delaying treatment for further imaging does not threaten the extremity

54
Q

what is the treatment of acute limb ischemia due to thromboembolism?

A

1) Systemic anticoagulation with an IV heparin bolus followed by continuous infusion unless a contraindication is present
2) Further management depends on the severity of acute limb ischemia.
- -Viable, non-threatened limb
* Urgent angiography to localize the site of the occlusion
* Revascularization procedure (open or catheter-directed thrombectomy or thrombolysis) within 6–24 hours
- -Threatened limb: emergent revascularization procedure within 6 hours
* First-line: catheter-directed thrombolysis and/or percutaneous mechanical thromboembolectomy (e.g., balloon catheter embolectomy)
* Second-line: open thromboembolectomy
- -Non-viable limb: limb amputation

55
Q

what is the most common source of embolism leading to acute limb ischemia?

A

Atrial fibrillation

Cardiorespiratory (24 decks)

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