Lecture 15: PAD Part 1 Flashcards by Enoch Koo

What is PAD?

Stenosis or occlusion in the aorta or arteries in the limbs

How well did you know this?

Not at all

Perfectly

MCC of PAD

Atherosclerosis in patients > 40y

How well did you know this?

Not at all

Perfectly

Hallmark sign of PAD

Intermittent claudication

Claudication = muscle pain due to hypoxia but relived by rest.

How well did you know this?

Not at all

Perfectly

What kind of vessels does PAD tend to affect?

Middle-large size vessels

How well did you know this?

Not at all

Perfectly

MCC two arteries affected in PAD

Femoral and popliteal arteries

Esp at arterial branch points/bifurcations

How well did you know this?

Not at all

Perfectly

Strongest risk factors for PAD

DM
Smoking
Hypercholesterolemia
HTN
Renal insufficiency

1st two are most important

How well did you know this?

Not at all

Perfectly

Who gets evaluated for PAD?

> =70
50-69 w/ smoking or DM
40-49 w/ DM and additional risk factor
Anyone with known atherosclerosis

How well did you know this?

Not at all

Perfectly

MC sites of atherosclerosis in PAD

Femoral-popliteal
Tibial artery
Distal aorta and proximal common iliac disease (white smokers)

smoking is also the main risk factor for AAA, which is the location of #3

How well did you know this?

Not at all

Perfectly

What are the common clinical presentations for PAD?

Asymptomatic
Atypical leg pain (MC)
Classic claudication
Critical limb ischemia

How well did you know this?

Not at all

Perfectly

Describe claudication.

Occurs during exercise and relieved with rest
Reproducible symptom
The most typical symptom of PAD.

How well did you know this?

Not at all

Perfectly

2 MCC of pseudoclaudication/neurogenic claudication

Spinal cord stenosis
Herniated disc impairment or scaiatic nerve

How well did you know this?

Not at all

Perfectly

Claudication vs pseudoclaudication chart

How well did you know this?

Not at all

Perfectly

What is often the first sign of vascular insufficiency in PAD?

Rest pain or ulceration that is confined to the dorsum of the foot and requires dependency.

Often occurs at night.

Dependency means the patient needs to hang their foot over the side of the bed

How well did you know this?

Not at all

Perfectly

What characterizes critical limb ischemia?

Ischemic rest pain
Ulceration
Gangrene

Essentially claudication, but the pain does NOT relieve with rest.

How well did you know this?

Not at all

Perfectly

What is the MC anatomic classification scale used in PAD?

Trans-Atlantic Inter-Society Consensus (TASC II)

How well did you know this?

Not at all

Perfectly

What classification is used for clinical severity of chronic lower extremity ischemia?

WIFi (Wound, ischemia, and foot infection)

Used to determine if you need to amputate.

How well did you know this?

Not at all

Perfectly

Classic findings in patients with PAD

Decreased or absent pulses distal to the obstruction
May need to use hand-held doppler

What are normal pulses graded as on PE?

2+, brisk, expected

Buerger/leg lift test for PAD

Elevate leg to 60deg for 1 minute
Positive if pallor occurs since arterial pressure is lacking.
Extremely positive if dependent rubor also occurs (when u drop the foot back down and it gets extremely red)

A normal foot shouldn’t turn white that fast

First-line screening for PAD

Ankle brachial index test

When is further testing of PAD required?

Only if ABI is a false negative or invasive interventions are needed.

Otherwise, it is a clinical diagnosis.

How to diagnose PAD

Clinically, only need ABI(<0.9) + history + PE

What is diagnostic of PAD on ABI?

Anything less than 0.9

How do you measure ABI?

Highest SBP of PT or DP
divided by brachial SBP

Must do ABI on each side.

PT = posterior tibial
DP = dorsalis pedis

Limitations of ABI

* Incompressible arteries (> 1.4) * Resting may be useless if good collateral circulation was made * Does not measure the degree or severity or location of PAD.

When do we do toe brachial index screening?

When ABI > 1.40 | aka non-compressible arteries

What is abnormal/diagnostic TBI?

TBI <= 0.7 = PAD

What do TBIs predict?

Better value = better **healing**

When can you not use a treadmill test for PAD?

* Non-compressible vessels (ABI > 1.4) * Cannot walk on a treadmill (unstable angina, etc)

What is diagnostic of PAD for treadmill stress tests?

Decrease in ABI of more than 20% following exercise.

What is segmental limb pressure used for and what is considered diagnostic?

Specific location of artery that has PAD, which is **diagnosed by a decrease of >30 mm Hg between two consecutive** segments.

What is arterial duplex mainly used for?

Determining severity and to assess risk/benefit for intervention. | **Never use as a screening tool!!!!!!!!!!**

When is MRA indicated and what is the primary CI?

MRA is indicated to assess benefit of surgery and gadolinium cannot be used in ppl with GFR < 30 | Does not use ionizing radiation or ionized contrast ## Footnote **NOT SCREENING TEST**

Difference between MRA and CTA

CTA uses **iodinated** contrast and **ionized radiation.** ## Footnote MRA uses gadolinium, which is not iodinated.

What is the gold standard imaging test for PAD?

Digital subtraction angiography (DSA) | Done by IR to **guide intervention.**

What two antiplatelets are indicated for PAD?

ASA alone or plavix alone for symptomatic atherosclerotic lower extremity PAD | Only reasonable for asymptomatic ## Footnote Do not do DAPT until they have had intervention.

What should you advise a patient on EVERY SINGLE VISIT for PAD?

Smoking cessation

What is the MOA and indication for cilostazol?

* **Vasodilator + antiplatelet that improves symptoms** in PAD. * **Protein-bound (can't eat with food)** * No vasodilation in renal arteries * PDE inhibitor | 100mg PO BID

Who is cilostazol CId in?

Heart failure patients

When is bypass or endovascular therapy indicated for PAD?

Continued intermittent claudication sx's or CLI.

What are the 3 types of endovascular therapy?

* Angioplasty * Stenting * Atherectomy