B P5 C43 Peripheral Artery Diseases Flashcards
(129 cards)
1
Q
________________ generally refers to acute or chronic obstruction of the arteries supplying the lower or upper extremities that, when severe, results in downstream ischemia and potentially tissue loss.
A
Peripheral artery disease
Most often caused by atherosclerosis, PAD may also result from thrombosis, embolism, vasculitis, fibromuscular dysplasia (FMD), or entrapment.
2
Q
__________________, _______________, __________________ account for about 75% of the risk of developing PAD
A
Smoking, type 2 diabetes mellitus (DM), hypertension, and hypercholesterolemia
3
Q
________________ results from an oxygen (O2) supply mismatch analogous to angina in patients with stable angina
A
Intermittent claudication
4
Q
Patients with intermittent claudication may have single or multiple occlusive lesions in the arteries supplying the limb.
Blood flow and leg O2 consumption are normal at ______ , but the obstructive lesions limit blood flow and O2 delivery during exercise such that the metabolic needs of the exercising muscle outstrip the available supply of O2 and nutrients
A
Rest
5
Q
There is considerable heterogeneity in patterns of occlusive disease including medial artery calcification and a predominance of below knee disease particularly in patients with _____________ and ___________
A
Diabetes and/or CKD
6
Q
The cardinal symptoms of PAD include limb pain either with exercise (_______________________) or at rest
A
Intermittent claudication
7
Q
________________refers to a pain, ache, sense of fatigue, or other discomfort that occurs in the affected muscle group with exercise, particularly walking, and resolves with rest.
A
Intermittent claudication
8
Q
Symptoms or tissue loss occur at ______ in patients with CLI.
A
Rest
Typically, patients complain of pain or paresthesias in the foot or toes of the affected extremity. This discomfort worsens with leg elevation and improves with leg dependency, as might be anticipated by the effect of gravity on perfusion pressure. The pain can be particularly severe at sites of skin fissuring, ulceration, or necrosis.
9
Q
Characteristic of a venous ulcer
A
Localizes near the medial malleolus Irregular border
Pink base with granulation tissue
Produce milder pain
10
Q
Characteristic of a neuropathic ulcer
A
Occur at sites of pressure or trauma, usually on the sole of the foot
Ulcers are deep
Frequently infected,
Mot generally painful because of the loss of sensation
11
Q
Physical findings of ____________ and _________ increase the likelihood of PAD
A
Pulse abnormalities and bruits
12
Q
_____________ are often a sign of accelerated blood flow velocity and flow disturbance at sites of stenosis. A
A
Bruits
13
Q
Signs of chronic low grade ischemia vs severe lim ischemia
A
Chronic low-grade ischemia - hair loss, dystrophic, thickened and brittle toenails, smooth and shiny skin, and atrophy of the subcutaneous fat of the digital pads
Severe limb ischemia - cool skin and may also have petechiae, persistent cyanosis or pallor, dependent rubor, pedal edema resulting from prolonged dependency, skin fissures, ulceration, or gangrene.
14
Q
Charcteristics of arterial ulcers
A
Pale base
Irregular borders
Involve the tips of the toes or the heel of the foot or develop at sites of pressure
Vary in size and may be as small as 3 to 5 mm.
15
Q
Give the Fontaine classification
Presence of rest and nocturnal pain
A
Fontaine III
16
Q
Give the Rutherford classification
Ischemic rest pain
A
Rutherford Grade II Category 4
17
Q
_____________________ advanced PAD with rest pain, gangrene, or ulceration of greater than 2 weeks.
A
Chronic limb threatening ischemia
18
Q
__________ acknowledges and evaluates the m tifactorial nature of wounds in patients with PAD including wound characteristics, infection, and ischemia
A
WIFI (Wound, Ischemia, and Foot Infection)
19
Q
Measurement of SBP along sequential segments of each extremity is one of the simplest noninvasive measures for ascertaining the presence and severity of stenoses in the peripheral arteries.
A
Segmental pressure measurement
20
Q
SBP may be higher in the more distal vessels than in the aorta and proximal vessels because of _____________________________
A
A mplification and reflection of BP waves.
21
Q
Approximately _______ of the cross-sectional area of the aorta must be narrowed before a pressure gradient develops.
In smaller vessels, such as the iliac and femoral arteries, a _____________ decrease in cross-sectional area will cause a resting pressure gradient sufficient to decrease SBP distal to the stenosis.
A
Aorta - 90%
Iliac and Femoral, smaller vessels - 70% to 90%
22
Q
A BP gradient in excess of _____________ between successive cuffs is generally used as evidence of arterial stenosis in the LE
A
20 mm Hg
23
Q
A gradient of _________ indicates a stenosis between sequential cuffs in the upper extremity.
A
10 mm Hg
24
Q
SBP in the toes and fingers is approximately _______ of SBP at the ankle and wrist, respectively, because pressure diminishes further in the smaller distal vessels.
A
60%
25
Identify the location of the stenosis
A pressure gradient is present between the left upper and lower thigh cuffs, lower thigh and calf cuffs, and calf and ankle cuffs, consistent with multisegmental disease affecting the femoral-popliteal and tibial arteries.
26
__________ ratio of SBP measured at the ankle to SBP measured at the b chial artery.
Ankle-Brachial Index
27
Classification of ABI
Normal - 1.00 - 1.40
Borderline - 0.91 - 0.99
Abnormal 0.9 or less
An ABI of 0.90 or lower has a specificity of 83% to 99% and a sensitivity of 69% to 73% in detecting stenoses greater than 50%
28
Patients with symptoms of leg claudication often have an ABI ranging from _____________, and patients with CLI usually have an ABI _____________
0.5 to 0.8
0.4 and lower
29
An ankle SBP less than _____________ predicts poor ulcer healing.
55 mm Hg
30
An ABI higher than _______ indicates a noncompressible artery, and the test is not informative for either confirming or excluding PAD
1.40
31
In case of noncompressibel arteries, _____________ should be used
Ratio of _________ or higher reflects normal perfusion pressure
Toe-brachial index
Ratio of 0.70 or higher reflecting normal perfusion pressure
32
________________ can be used to evaluate the clinical s icance of peripheral artery stenoses and provide objective evidence of the patient’s walking capacity.
Treadmill Exercise Testing
This provocative test should be considered in patients with risk factors and symptoms suggestive of vascular claudication but with normal resting ABI, as may occur in those with proximal disease.
33
The ___________________ is when symptoms of claudication first develop, and the ________________ occurs when the patient can no longer continue walking because of severe leg discomfort.
Claudication onset time
Peak walking time
34
A ______________________ in the ABI after exercise in a patient whose walking capacity is limited by claudication is considered diagnostic and implicates PAD as a cause of the patient’s symptoms.
25% or greater decrease
BP increase that occurs during exercise should be the same in both the upper and the lower extremities, with a constant ABI of 1.0 or greater being maintained. In the presence of peripheral artery stenoses, however, the ABI decreases because the BP increase observed in the arm is not matched by a comparable increase in ankle BP.
35
_____________ graphically illustrates the volumetric change in a segment of the limb that occurs with each pulse.
Pulse Volume Recording
36
Normal pulse volume contour
Sharp systolic upstroke rising rapidly to a peak, a dicrotic notch, and a concave downslope that drops off gradually toward the baseline
37
Stenotic pulse contour
Loss of the dicrotic notch, a slower rate of rise, a more rounded peak, and a slower descent.
The amplitude becomes lower with increasing severity of disease, and the pulse wave may not be recordable at all in a critically ischemic limb.
38
Normal doppler waveform
Rapid forward-flow component during systole
Transient flow reversal during early diastole
Slow anterograde component during late diastole
39
Stenotic doppler flow
Deceleration of systolic flow, loss of the early diastolic reversal, and diminished peak frequencies
Arteries in a limb with critical ischemia may not show any Doppler frequency shift.
40
provides a direct, noninvasive means of assessing both the anatomic characteristics of peripheral arteries and the functional significance of arterial stenoses
Duplex Ultrasound Imaging
41
A ___________________ in peak systolic velocity at the site of an atherosclerotic plaque indicates a 50% or greater stenosis
Twofold or greater increase
42
A threefold increase in velocity suggests a ______________ stenosis
75% or greater
43
______________ has its greatest usefulness in the evaluation of s tomatic patients to assist in decision making before endovascular and surgical intervention or in patients at risk for renal, allergic, or other complications during conventional angiography.
Magnetic Resonance Angiography
44
permits imaging of peripheral arteries with excellent spatial resolution during a relatively short time and with limited amounts of radiocontrast material
Computed tomography
45
Those with the most severe symptoms of PAD, notably those with _______, have the worst prognosis with high rates of amputation and mortality.
CLI
46
Class I recommendations in the medical tx for PAD
Treatment with a statin medication is indicated for all patients with PAD.
Antihypertensive therapy should be administered to patients with hypertension and PAD to reduce the risk of MI, stroke, heart failure, and cardiovascular death.
Patients with PAD who smoke cigarettes or use other forms of tobacco should be advised at every visit to quit.
Patients with PAD should have an annual influenza vaccination
Management of diabetes mellitus in the patient with PAD should be coordinated between members of the health care team
47
Class 1 recommendation regarding antiplatelet tx in PAD
Antiplatelet therapy with aspirin alone (range, 75–325 mg/day) or clopidogrel alone (75 mg/day) is recommended to reduce MI, stroke, and vascular death in patients with **symptomatic PAD**.
48
The _____________ trial compared clopidogrel with aspirin in reducing ischemic events in patients with recent myocardial infarction, recent ischemic stroke, or PAD. Overall, clopidogrel reduced vascular death, myocardial infarction, or stroke by 8.7% versus aspirin. 84 Notably, among the 6452 patients in the PAD subgroup, clopidogrel treatment appeared to be associated with a greater 23.8% relative risk reduction.
CAPRIE trial (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events)
49
Data demonstrate that antiplatelet monotherapy reduces CV risk in patients with _______________, but it is of uncertain benefit in those with a marginally low ABI and no symptoms.
Symptomatic PAD
50
The most common application of DAPT in patients with PAD is in the _____________________ where benefits after endovascular intervention have been largely extrapolated from the coronary setting
Postintervention setting
51
The only randomized trial of DAPT after revascularization was the ___________ trial; DAPT versus aspirin did not reduce the primary composite endpoint of graft occlusion, revascularization, amputation, or death in patients undergoing belowknee bypass surgery for PAD and moderate or severe bleeding was increased.
CASPAR (Clopidogrel and Acetylsalicylic Acid in Bypass Surgery for Peripheral Artery Disease)
Overall, there are data to support antiplatelet monotherapy for MACE reduction in PAD, but data for MALE benefit are mixed. The efficacy of DAPT is supported for the reduction of MACEs and MALEs in patients with both PAD and CAD (polyvascular disease), although there is increased bleeding risk.
52
Randomized 27,359 patients with s ble atherosclerotic vascular disease, including lower extremity PAD to rivaroxaban 2.5 twice daily with aspirin, rivaroxaban 2.5 mg twice daily, or aspirin monotherapy.
The majority of patients with PAD had concomitant CAD (polyvascular disease).
The trial was ended early for overwhelming benefit and demonstrated a 24% reduction in MACEs for the rivaroxaban plus aspirin arm versus aspirin alone, while the rivaroxaban only arm did not show superiority.
The benefits extended to reductions in CV death and all-cause mortality.
The benefit was accompanied by a 70% increase in major bleeding but no statistically significant increase in intracranial hemorrhage or fatal bleeding.
COMPASS trial (Cardiovascular Outcomes for People Using Anticoagulation Strategies)
In addition to benefits for MACEs, rivaroxaban significantly reduced the secondary endpoint of MALEs by approximately 45% with consistent effects for ALI and major vascular amputation. The greatest absolute benefits for reducing MALEs in COMPASS were observed in patients with symptomatic PAD with a history of prior revascularization relative to those with no history of revascularization, with little absolute benefit in those with asymptomatic PAD detected by a low ABI
53
Tested the same strategy of aspirin and rivaroxaban 2.5 mg twice daily versus aspirin alone in a broader PAD population selected only on the basis of symptomatic lower extremity PAD requiring intervention
Only approximately one third had coronary disease and approximately 10% had a prior myocardial infarction (sa COMPASS mas marami may CAD)
the combination of aspirin and rivaroxaban 2.5 twice daily was superior to aspirin alone, with a 15% relative risk reduction and 2.6% absolute risk reduction at 3 years
VOYAGER PAD trial
54
The MACE benefits were greatest in the ___________ population and the subgroup of VOYAGER PAD patients with concomitant CAD (polyvascular disease) while the
Limb benefits were greatest in __________ and the subset of COMPASS with prior LER.
Although rivaroxaban increased bleeding, there was a net benefit in both studies with a 6:1 benefit-risk ratio in VOYAGER PAD.
COMPASS - MACE in CAD (kapag VOYAGER sa may concomittant CAD lang)
VOYAGER PAD - MALE (kapag sa COMPASS yung may prior revasc lang)
55
______________ is an effective therapy to improve symptoms and increase walking distance in patients with claudication
Cilostazol
56
_____________ reduces the risk for developing symptomatic PAD and lessens the risk of progression to CLI and amputation in those with PAD.
Smoking cessation
57
The most effective noninvasive intervention for improving limb-related symptoms. T
Exercise training
58
Much of the benefit of exercise training likely results from ________________________, such as increased muscle mitochondrial enzyme activity, oxidative metabolism, and ATP production rate
Changes in skeletal muscle structure or function
59
Supervised exercise training increases maximal walking time by _____________
50% to 200%
The greatest benefit occurs when sessions are at least 30 minutes in duration, when sessions take place at least three times per week for 6 months, and when walking is the mode of exercise.
60
___________ quinolinone derivative that inhibits phosphodiesterase 3 (PDE3), thereby decreasing degradation of cyclic adenosine monophosphate and increasing its concentration in platelets and blood vessels.
Cilostazol
61
Cilostazol improves absolute claudication distance by ____________ in comparison to placebo.
40% to 50%
62
Cilostazol should not be used in patients with ____________________ because other PDE3 inhibitors decrease survival in these patients.
Congestive heart failure
63
________________ indicated for selected patients with lifestyle-limiting claudication despite a trial of exercise rehabilitation or pharmacotherapy.
Peripheral catheter–based interventions
64
_______________ improves symptoms in patients with disabling claudication and is indicated to relieve rest pain and preserve limb viability in patients with CLI that is not amenable to percutaneous interventions.
Surgical revascularization
65
The most frequent open surgical operation performed in patients with aortoiliac disease.
Aortobifemoral bypass
66
Five patency rates for aortobifemoral bypass grafts exceed ______
80%
67
These bypass grafts circumvent the aorta and iliac arteries and are generally used in high-risk patients with CLI.
Extra-anatomic surgical reconstructive procedures
Fiveyear patency rates range from 50% to 70% for axillobifemoral bypass operations and from 70% to 80% for femoral-femoral bypass grafts.106 The operative mortality rate for extra-anatomic bypass procedures is 3% to 5%
68
Graft stenoses can result from technical errors at surgery, such as retained valve cuffs or intimal flap or valvotome injury; from ________________, usually within 6 months of surgery; or from _____________, which usually occurs within the vein graft at least 1 to 2 years
Fibrous intimal hyperplasia - within 6 months
Atherosclerosis - at least 1-2 years
69
Medical tx for symptomatic PAD with prior revascularization
Smoking cessation, diet, exercise
ASA + Rivarixaban (if low bleeding risk)
High intensity statin +/- Eze and/or PCSK9i
ACEi for HPN
GLP 1 or SGLT2 for DM
Exercise
Cilostazol
70
A segmental vasculitis that involves the distal arteries, veins, and nerves of the upper and lower extremities, typically affects younger persons who smoke.
Thromboangiitis Obliterans
71
TAO primarily affects the ___________________ of the arms, including the radial, ulnar, palmar, and digital arteries, and their counterparts in the legs, including the tibial, peroneal, plantar, and digital arteries.
Medium and small vessels
72
Pathologic findings in TAO
An occlusive, highly cellular thrombus that incorporates polymorphonuclear leukocytes, microabscesses, and occasionally multinucleated giant cells.
73
________________ is present in virtually every patient with TAO.
Tobacco use or exposure
Hypercoagulability, immunologic mechanisms, and endothelial dysfunction may contribute to the pathogenesis of TAO.
74
Patients with TAO can have claudication of the __________________
Most patients with TAO have pain at rest and digital ulcerations; frequently, __________________ is affected.
Hands, forearms, feet, or calves
More than one extremity
75
___________________ occurs in approximately 45% of patients with TAO, and ____________________, which may be migratory, develops in approximately 40%.
Raynaud phenomenon
Superficial thrombophlebitis
76
Diagnosis of TAO relies on
Age at onset of younger than 45 years
History of tobacco use
Physical examination demonstrating distal limb ischemia
Exclusion of other diseases
Angiographic demonstration of typical lesions
77
Arteriographic findings in TAO
Segmental occlusion of small and medium arteries, absence of atherosclerosis, and corkscrew collateral vessels circumventing the occlusion
These same findings, however, can occur in patients with scleroderma, SLE, mixed connective tissue disease, and antiphospholipid antibody syndrome.
78
The conclusive test for TAO is a _____ showing the classic pathologic findings. However, this procedure is rarely indicated, and sites may fail to heal because of severe ischemia
Biopsy specimen
79
The diagnosis of TAO therefore usually depends on _____
Age at onset < 45 years
History: tobacco use
PE: distal limb ischemia
Exclusion of other diseases
Angiographic demonstration of typical lesions
80
The cornerstone of TAO treatment is ________________________
Cessation of tobacco use
81
Trigger avoidance beyond smoking cessation in TAO is recommended including _____________________ as well as other chemical or mechanical sources of injury.
Avoidance of cold exposures
82
_____________________, a prostacyclin analogue, may be more effective than aspirin for rest pain and ischemic ulcers inpatients with TAO
Intravenous iloprost
Oral iloprost is not effective
83
_____ definitive drug therapy is available for TAO.
No
Vascular reconstructive surgery is not usually a viable option because of the segmental nature of this disease and the involvement of distal vessels.
**Sympathectomy** may improve some symptoms of TAO.
**Hyperbaric oxygen therapy** may improve healing and reduce amputations although reports are limited to small patient numbers.
In severe refractory cases, **bosentan** can be considered based on observed healing in a case series.
84
A noninflammatory disorder that affects **medium and large arteries**, typically the renal, carotid, and vertebral arteries
Fibromuscular Dysplasia
It also may involve the arteries supplying the leg, particularly the iliac arteries and less often the femoral, popliteal, tibial, and peroneal arteries
85
FMD rarely causes _____________
Intermittent claudication or CLI
86
FMD most often affects ____________
Women
87
Aneurysm or dissection is present in more than ___% of patients at diagnosis of FMD.
40%
88
The most frequent presenting signs and symptoms are _____ that should prompt consideration of FMD
Hypertension
Headache
Pulsatile tinnitus
Dizziness
89
Clinical Circumstances Prompting Consideration of Fibromuscular Dysplasia
Hypertension <35 years old or resistant hypertension at any age
Epigastric bruit and hypertension
Transient ischemic attack, stroke, or cervical bruit in a patient <60 years old
Symptomatic PAD in a woman <60 years old without atherosclerotic risk factors
Subarachnoid hemorrhage
Pulsatile tinnitus
Severe and recurrent headaches
Peripheral artery dissection or spontaneous coronary artery dissection
Visceral or intracranial aneurysm
Aortic aneurysm in a patient <60 years old
Renal infarction
90
Histopathologic examination shows fibroplasia most often affecting the ____________, but it can involve the intima or adventitia.
Media
91
The more common subtype and presents with the classic “string of beads” and has been pathologically associated with intimal fibroplasia, medial hyperplasia, and to perimedial fibroplasia.
Multifocal FMD
92
Appears as a tubular stenosis, is less common, and is pathologically associated with medial hyperplasia and periarterial hyperplasia
Focal FMD
93
This occurs when an anatomic variation in the confiiguration or insertion of the medial head of the gastrocnemius muscle compresses the popliteal artery
Popliteal artery entrapment syndrome
The popliteus muscle also can compress the popliteal artery
94
Popliteal artery entrapment is ___________ in approximately one third of affected patients. It should be suspected when a _____________ person is evaluated for claudication
Bilateral
Young, typically athletic, usually male
95
Walking or ___________________________ maneuvers may cause attenuation or disappearance of the pedal pulses and a decrease in the ABI in PAES
Repeated ankle dorsiflexion and plantar flexion
96
Treatment of popliteal artery entrapment syndrome involves ___________________, which may require division and reattachment of the medial head of the gastrocnemius muscle.
Release of the popliteal artery
97
occurs when an arterial occlusion suddenly reduces blood flow to the arm or leg.
Acute Limb Ischemia
98
This constellation of symptoms and signs is often recalled as the “six Ps”:
Pain, paresthesias, pallor, pulselessness, poikilothermia, and paralysis
Findings on physical examination can include absence of pulses distal to the occlusion, cool skin, pallor, delayed capillary return and venous filling, diminished or absent sensory perception, and muscle weakness or paralysis.
99
Classify ALI
Sensory loss ankle and above, moderate weakness, absence of pulses
IIB - Immediately Threatened
100
Causes of ALI include ____________
Embolism
Thrombosis in situ
Dissection
Trauma
Majority are embolic
101
Most arterial emboli arise from thrombotic sources in the heart, as occurs in ________________, or other sources such as prosthetic cardiac valves, paradoxical embolism, and cardiac tumors such as left atrial myxomas.
Atrial fibrillation
102
____________________ may lead to embolization of thrombus to more distal arterial sites and usually lodge at branch points where the artery decreases in size
Aneurysms of the aorta or peripheral arteries
103
In patients with established PAD, causes of ALI include
In situ atherothrombosis
Graft thrombosis
Stent thrombosis
104
___________________ occurs in atherosclerotic peripheral arteries, infrainguinal bypass grafts, peripheral artery aneurysms, and normal arteries of patients with hypercoagulable states
Thrombosis in situ
105
One of the most common causes of ALI in patients with PAD is ________________
Thrombotic occlusion of an infrainguinal bypass graft
106
The _____ usually establish the diagnosis of ALI.
History and PE
Tests should not delay urgent revascularization procedures to rescue a limb with threatened viability
107
A _____ probe can assess the presence of blood flow in peripheral arteries, even when pulses are not palpable in ALI.
Color-assisted duplex ultrasonography can determine the site of occlusion, particularly to evaluate the _____.
Doppler
Patency of infrainguinal bypass grafts
108
Clinical categories of ALI
I. VIABLE: Not immediately threatened
SL: None
MW: None
Doppler: A: Audible; V: Audible
II. Threatened
A: Marginally: Salvageable if treated promptly
SL: Minimal (toes) or none
MW: None
Doppler: A: Often inaudible; V: Audible
B. Immediately: Salvageable with immediate revasc
SL: > toes, rest pain
MW: mild-moderate
Doppler: A: usually inaudible; V: Audible
III. Irreversible: Major tissue loss/ Permanent nerve damage inevitable
SL: Profound, anesthetic
MW: Profound, paralysis(rigor)
Doppler: A: Inaudible; V: Inaudible
109
Initial treatment for patients with acute leg ischemia:
(1) Bed should be positioned such that the **feet are lower than chest level**, thereby increasing limb perfusion pressure by hydrostatic effects.
(2) Effort should be made to **reduce pressure on the heels, on bone prominences, and between the toes** by appropriate placement of soft material on the bed (e.g., sheepskin) and between the toes (e.g., lambswool).
(3) **Heparin** should be administered intravenously immediately. The dose should maintain the APTT at **2.0 to 2.5** times control values or titrated to factor Xa levels depending on local practice and with a goal to prevent propagation of thrombi or recurrent embolism
110
______________ should be administered intravenously immediately.
Heparin
The dose should maintain the partial thromboplastin time at 2.0 to 2.5 times control
111
_____________________ is indicated when the viability of the limb is threatened or when symptoms of ischemia persist
Revascularization
112
Initial treatment option for patients with either category I or II ALI if they have no contraindication to thrombolysis.
Catheter-directed intra-arterial thrombolysis plus thrombectomy
113
Diagnostic and treatment approach for patients with ALI
(1) Initial IV Heparin
(2)
Stage I: Imaging then revascularization
Stage IIa: Imaging then revascularization
Stage IIb: Imaging if no delay in emergency revascularization
Stage III: Amputation
114
Catheter-based thrombolytic therapy should graduallyally be continued for __________ to achieve optimal benefit and to limit the risk for bleeding.
24 to 48 hours
115
Catheter-based thrombolysis is an appropriate initial option in patients with viable or marginally threatened limbs and when the ischemia is of ________________ duration
Less than 14 days
116
Surgical revascularization is more appropriate in those with immediately threatened limbs and in those whose symptoms have lasted for _____________
Patients with irreversible injury require amputation
More than 14 days
117
Long-term ______________ therapy is usually indicated for patients with an embolic source, such as atrial fibrillation.
Anticoagulation
118
Refers to occlusion of arteries resulting from detachment and embolization of **atheromatous debris, including fibrin, platelets, cholesterol crystals, and calcium fragments**.
Atheroembolism
119
Atheroemboli originate most frequently from ______ of the aorta and less frequently from atherosclerotic branch arteries.
“Shaggy,” protruding atheroma
The atheroemboli typically occlude small downstream arteries and arterioles of the skin, extremities, brain, eyes, kidneys, or mesentery.
120
Most affected individuals are __________________ with clinical evidence of atherosclerosis.
Men older than 60 years
121
_________________ may also cause atheroemboli in approximately 1% to 2%
Catheter manipulation
Similarly, surgical manipulation of the aorta during cardiac or vascular operations may precipitate atheroembolism
122
The most notable clinical features of atheroembolism involving the extremities include painful cyanotic toes, called _________________
“blue toe syndrome”
123
_________________ occurs in approximately 50% of patients with atheroembolism.
Livedo reticularis
124
Pedal pulses are typically present in atheroembolism because the emboli tend to lodge in the _____.
More distal digital arteries and arterioles
125
Laboratory findings consistent with atheroembolism include an _____.
Elevated ESR
Eosinophilia
Eosinophiluria
126
Imaging of the aorta with _____ may identify sites of severe atherosclerosis indicating a source of the atheroemboli
TEE
MRA
CTA
127
The only definitive test for atheroembolism is pathologic confirmation on ___________________ specimens.
Skin or muscle biopsy
128
Pathognomonic findings in atheroembolism include _____.
* Elongated needle-shaped clefts in small arteries caused by cholesterol crystals
* Accompanied by inflammatory infiltrates composed of lymphocytes and possibly giant cells and eosinophils, intimal thickening, and perivascular fibrosis
129
Treatment of atheroembolism
* No definitive treatment has been established for atheroembolism.
* Local foot care should be provided as with ALI.
* It may be necessary to excise or amputate necrotic areas.
* Risk factor modification, such as lipid-lowering therapy with statins and smoking cessation, can favorably affect the overall outcome of atherosclerosis
* Surgical removal of the source should be considered in patients with atheroembolism, particularly in those with recurrence.
Controversial:
Antiplatelets
Warfarin
Corticosteroids
