Chapter 105 - Lower extremity arterial disease - medical management and decisions

Question 1

PAD prevalence overall and age distributed

Answer 1

4.3% 40-49 years: 0.9% 50-59 years: 2.5% 60-69 years: 4.7% >69 years: 14.5%

Question 2

5 years course of intermittent claudication

Answer 2

amputation 1-7% deterioration 25%

Question 3

CLTI cardiovascular mortality in 1, 5 and 10 years

Answer 3

1 year: 12% 5 years: 42% 10 years: 65%

Question 4

Chronic subclinical LE ischemia definition

Answer 4

ABI < 0.9 without IC or CLTI usually due to limitation of other comorbidity

Question 5

Ambulation rate of decline in I.C.

Answer 5

8.4 m/yr

Question 6

Structured exercise survival benefit in 5 years

Answer 6

80.5% vs 56.7%

Question 7

ACC/AHA recommendation on exercise

Answer 7

30-45 min x 3-4/week for 12 weeks

Question 8

Percentage of patients with I.C. where exercise therapy can be completed

Answer 8

1/3

Question 9

Two FDA approved drugs for PAD

Answer 9

1) Pentoxifylline (Trental) 2) Cilostazol (Pletal)

Question 10

Cilostazol MOA

Answer 10

Phosphodiesterase III inhibitor –> increase cAMP 1) SMC relaxation 2) inhibit platelet aggregation 3) decrease SMC proliferation 4) decrease TG, increase HDL 5) increase VEGF

Question 11

Effect of cilostazol

Answer 11

1) increase walking distance by 50% 2) increase quality of life

Question 12

Side effects of cilastazol

Answer 12

1) headache 2) diarrhea and other GI symptoms 3) CHF exacerbation 4) interact with cytochrome p450 system

Question 13

Contraindication of cilastazol

Answer 13

CHF

Question 14

Dose of Cilostazol

Answer 14

100 mg po BID start slow titrate up

Question 15

Cilostazol vs pentoxifylline

Answer 15

Cilostazol better at increasing walking distance

Question 16

TASC definition

Answer 16

Trans Atlantic Inter Society Consensus

Question 17

TASC purpose

Answer 17

1) gauge extent of angiographic disease 2) aid in decision making

Question 18

What % of CLTI post-op bypass does not show clinical improvement despite graft patency

Answer 18

10%

Question 19

Specific names of QOL PAD surveys

Answer 19

1) SF36 2) Nottingham Health Profile

Question 20

Endpoint in I.C. treatment

Answer 20

Quality of life

Question 21

Endpoint for CLTI based on Taylor et al in Rutherford class 5/6 bypass success

Answer 21

1) Patent until wound heal 2) Limb salvage 1 year 3) ambulatory 1 year 4) survival 6 months Total probability 44%

Question 22

TASC and TASC II years

Answer 22

TASC 2000 TASC II 2007

Question 23

Run off score

Answer 23

0 < 20% stenosis 1: 20-50% stenosis 2: 50-99% stenosis 2.5: < half occluded 3: > half occluded

Question 24

Calcium score in PAD anatomy

Answer 24

0: none 1: < 25% 2: 25-50% 3:> 50% circumference

Question 25

Lesion length category

Answer 25

Short \< 6cm Intermediate 7-10cm Long \> 10cm

Question 26

I.C. risk of amputation per year and cardiac death

Answer 26

Amputation 1% Cardiac death 3-5%/year

Question 27

Smoking cessation in I.C.

Answer 27

1) unclear if increases walking distance 2) reduces cardiovascular events

Question 28

Cilostazol cannot be used in this % of population and why

Answer 28

15% CHF

Question 29

ACC/AHA guideline for treatment of PAD

Answer 29

1) antiplatelet 2) cilostazol Class I evidence

Question 30

CLEVER study on PAD

Answer 30

Claudication: exercise vs endoluminal revascularization 6 month: walking time best in exercise \> stent \> drugs QOL: best in stent \> exercise \> drugs

Question 31

Amputation in I.C. patients post-op from revasc attempt

Answer 31

1.6% in 1 year

Question 32

Medical therapy only in PAD effectiveness

Answer 32

30%

Question 33

Johnson characteristics most ammenable to perc endo treatment

Answer 33

1) focal lesion 2) large diameter 3) adequate outflow

Question 34

CIA angioplasty patency in 5 year

Answer 34

70%

Question 35

% of IC that progress to CLTI

Answer 35

\< 5%

Question 36

Typical CLTI symptom duration and pressure measurement for diagnosis

Answer 36

2 weeks of symptoms Ankle pressure \< 50 toe pressure \< 30

Question 37

CLTI outcomes in amputation and death 1 year

Answer 37

25% amp 25% death

Question 38

Medical treatment only in CLTI amp rate

Answer 38

40% amputation at 6 months

Question 39

Decision in CLTI

Answer 39

1) medical vs intervention 2) amputation vs revasc 3) endo vs open

Question 40

Rate of primary amputation in CLTI

Answer 40

10-40%

Question 41

Unreconstructable CLTI rate

Answer 41

60%

Question 42

Factors that increase BKA healing

Answer 42

1) well-controlled comorbidities 2) palpable femoral 3) warm calf 4) no infection

Question 43

Immediate post-op prosthesis benefits

Answer 43

1) reduce revision (5.4 vs 27.6%) 2) 86% independent amublation rate 3) time to ambulation 15.2 days

Question 44

BASIL trial on 1 year amputation-free survival in bypass vs endo then bypass

Answer 44

Endo then bypass 40% Primary bypass 70%

Question 45

Situational perfusion enhancement

Answer 45

For healing wounds temporarily

Question 46

BASIL key points

Answer 46

1) 450 patients randomized to bypass vs POBA 2) 6 months AFS 21 vs 26% 3) 2 year surgery is better in AFS and survival

Question 47

BASIL 2

Answer 47

vein bypass vs best endo 600 patients primary outcome: amputation free survival

Question 48

BEST CLI

Answer 48

best endo vs best surgery 2100 patients primary outcome: MALE

Question 49

Mortality following LE bypass

Answer 49

1.8%

Question 50

Cardiac complication following LE bypass

Answer 50

7.2%

Question 51

Angiogenesis for CLTI possibilities

Answer 51

1) VEGF 2) HGF 3) stem cell

Question 52

Other research in CLTI

Answer 52

1) Hypoxia inducible factor pathway stimulation (prolyl-4-hydroxylase inhibitor, thioredoxin system, peroxome proliferator activated receptor gamma coactivator 1 alpha protein, micro RNA, oligonucleotide) 2) therapeutic ultrasound 3) immune modulation 4) viral gene transfer 5) antibiotic therapy 6) cell-free oxygen delivery vectors

Question 53

Decision tree analysis in revascularization of CLTI

Answer 53

1) revascularization vs primary amputation gives 1.1 QALYs 2) revascularization vs medical only gives 1.2 QALYs gain 3) revascularization least costly per QALY if 1 month patency \> 11%

Question 54

TASC C lesion decision tree

Answer 54

Stent if 1) primary patency \> 32% in 5 years 2) age \> 80 3) mortality periop of bypass \> 6%

Question 55

Pharmacologic treatment of claudication part 1

Answer 55

Question 56

Pharmacologic treatment of claudication part 2

Answer 56

Question 57

CLTI endpoints different types and definitions

Answer 57

Question 58

Taylor's probability of failure after bypass when clinical condition is present

Answer 58

2 factors: 33% success 3 factors: 10% success all 4 factors: 5% success hyperlipidemia doesn't count

Question 59

TASC II aorto-iliac lesions

Answer 59

Question 60

TASC II femoropopliteal lesions

Answer 60

Question 61

Morbidity after bypass surgery

Answer 61

Question 62

Comparison of different risk stratification scores in cardiovascular disease and PAD

Answer 62