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PAD Flashcards

1
Q

Anatomical definition of PAD

A

Anatomical: Structural atherosclerotic narrowing of any non-coronary vessel which limits blood flow to the limbs

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2
Q

Functional definition of PAD

A

Functional: Arterial narrowing causing a mismatch between organ supply and demand causing intermittent symptoms of claudication and/or tissue ischemia

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3
Q

Classifications of PAD:

A

a) Lower Extremity Disease
– Typically known as PAD
– Pain in the legs with walking or at rest (severe disease)

b) abdominal
– Aortic aneurysm
– Renal artery
– Mesenteric

c) Cerebral Vascular (Carotid)

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4
Q

Causes: Tobacco

A

– Single most important modifiable cause
– Ten-fold increase in relative risk, dose related
– Exposure to 2nd hand smoke also shown to promote changes to endothelium

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5
Q

Causes: Diabetes Mellitus

A

– Increases risk 2-4 times, due to endothelial and smooth muscle cell dysfunction
– Diabetes accounts for up to 70% of nontraumatic amputations performed
– Diabetes in combination with smoking: 30% risk of amputation in 5 years

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6
Q

Causes: Dyslipidemia

A

– Elevations of total cholesterol, LDL, and TG’s all correlated with accelerated PAD
– Correction via diet and/or medications=major improvement rates of stroke, MI

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7
Q

All Causes:

A
  1. Tobacco
  2. DM
  3. Dyslipidemia
  4. Hypertension
    – Especially, but not exclusively, related to stroke
  5. Inflammatory mediators
    – Homocysteine, fibrinogen, C-reactive protein, Lipoprotein (a), renal disease
  6. Age
  7. gender (male)-until after 85 then more women
  8. ethnicity (African Americans with higher risk)
  9. Obesity and physical inactivity
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8
Q

Prevalence of PAD

A
  1. Increases with age

2. 1/3 patients 70+ or 50-69 w/hx of DM or smoking

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9
Q

PAD Symptoms

A 
• Analogous to angina pectoris 
• Intermittent limb claudication
– Dull aching muscular discomfort induced by exercise and relieved by rest
– Often at discrete threshold of work 
• Atypical features common
– Fatigue
– Heaviness
– Dysesthesia or cold sensation 
•not nocturnal cramps or restless leg
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10
Q

Comprehensive Vascular Exam

A 
• Bilateral arm blood pressure (BP)
• Cardiac examination
• Palpation of the abdomen for aneurysmal disease
• Auscultation for bruits
• Examination of legs and feet

Pulse Examination
– Carotid
– Radial/ulnar
– Femoral
– Popliteal
– Dorsalis pedis
– Posterior tibial
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11
Q

Pulse Scale

A 
• Scale􏰁
– 0=Absent
– 1=Diminished
– 2=Normal
– 3=Bounding (aneurysm or AI)
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12
Q

Steps towards Dx of PAD

A
  1. Obtain history of walking impairment and/or limb ischemic symptoms􏰁
  2. Obtain a vascular review of symptoms􏰁
    • Leg discomfort with exertion
    • Leg pain at rest􏰂 non-healing wound􏰂 gangrene
  3. Results:
    -no leg pain
    -atypical
    -classic claudication
    -Chronic limb ischemia
    -acute limb ischemia
  4. For all of the above perform ankle-brachial index measurement
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13
Q

How to Perform ABI Exam

A
  • Performed with the patient resting in the supine position
  • All pressures are measured with an arterial Doppler and appropriately sized blood pressure cuff
  • Systolic pressures will be measured in the right and left brachial arteries followed by the right and left ankle arteries.
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14
Q

What is the ABI?

A

The ratio of the higher brachial systolic pressure and the higher ankle systolic pressure for each leg􏰁:

ABI=(ankle systolic P)/(higher brachial Psys)

≤ 0.90 is diagnostic of peripheral arterial disease

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15
Q

ABI Scale

A

1.00–1.29: Normal
0.91–0.99: Borderline, low normal
0.41–0.90: Mild-to-moderate disease
≤0.40: Severe disease
≥1.30: Noncompressible

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16
Q

Hemodynamic noninvasive tests

A
  • Resting Ankle-Brachial Index (ABI)
  • Exercise ABI
  • Pulse volume recordings
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17
Q

Pulse Volume Recordings

A

Measured all along the leg

-should be triphasic

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18
Q

Exercise ABI Testing:

A
  • Indicated when the ABI is normal or borderline but symptoms are consistent with claudication􏰂
  • An ABI fall post-exercise supports a PAD diagnosis􏰂
  • Assesses functional capacity (patient symptoms may be discordant with objective exercise capacity).
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19
Q

Color Duplex Testing

A

Significant stenosis because velocities are super high and a ton of color means a lot more turbulent blood flow

20
Q

Arterial Duplex US Testing

A

Duplex ultrasound
• diagnose anatomic location
• degree of stenosis

Duplex ultrasound of the extremities can be used to select candidates for:􏰁
(a) endovascular intervention (stent/PTA)
(b) surgical bypass
(c) to select the sites of surgical
anastomosis.

21
Q

MRA

A

MRA has virtually replaced contrast arteriography for PAD diagnosis

•Excellent arterial picture
• No ionizing radiation
• Noniodine–based intravenous contrast medium rarely causes renal insufficiency or allergic reaction
• ~10% of patients cannot utilize MRA because of􏰁
− Claustrophobia
− Pacemaker/implantable cardioverter-defibrillator
− Obesity

22
Q

CTA

A
  • Requires iodinated contrast
  • Requires ionizing radiation
  • Produces an excellent arterial picture
23
Q

Renal Artery Stenosis:

Causes?

A

Athersclerosis or Fibromuscular Dysplasia

24
Q

RAS: Atherosclerotic Etiology

A

– Increased prevalence in pts w/ CAD, CVD, PAD

– Risk factors essentially the same for each

25
RAS: FMD
– Accounts for 40% cases – Also seen in the carotid arteries – Congenital arterial abnormality of fibrous, muscular and elastic components * Different thing altogether: connective tissue disorder * typically affects young women * Any CT disease is going to affect vasculature: FMD, Marfan's, etc. **Beads on a string***
26
Renovascular HTN
Caused by renal artery stenosis (kidney senses low blood flow because of the blockage) • Thus it shoots out a lot of renin-->RAAS • Giving them meds doesn't do much to decrease their HTN – Secondary to atherosclerosis – usually origin and proximal segment of renal artery – Fibromuscular dysplasia – usually mid to distal segment of renal artery or carotid artery – Occlusion
27
AAA
• Def: perm localized dilation of an artery =/> 50% normal diameter – Dilatation >2x size of more proximal artery * At risk of dissection, high mortality if this occurs * Most often occur in infra-renal aorta
28
AAA: Prevalence
• Abdominal: Thoracic Aneurysms – Men 7:1 – Women 3:1 • Coexistence of other vascular dz increases incidence: – 5% pts w/ sx CAD have AAA – 10% pts with CVD or PAD have AAA * AAA affects 8% older men, 1.5% older women * 15,000 deaths/year in the US alone * Once rupture occurs, 75-90% mortality rate
29
AAA Screening
• Prior to 1996, insufficient evidence for or against screening: now with – Family History
30
Dx of AAA
• Ultrasound – Aorta, look at diameter – Renal artery, look at diameter and velocities to estimate stenosis • MRA • CT scan Goal: to adequately visualize the arteries for measurements and velocities
31
Carotid Artery Dz: Prevalence
* Third leading cause of death in the US * 500,000 new strokes each year * 160,000 strokes result in death annually * 15-20 billion dollars per year * 50% of patients with a stroke will have a second stroke within 5 years if untreated
32
Stroke: Causes
``` • Only 10% of strokes preceded by TIA’s • 15% from a cardiac source • >33% of strokes associated with extracranial disease (like the carotids!) ```
33
a) Definition of a stroke b) ischemic c) hemorrhagic
* Sudden brain damage * Lack of blood flow to the brain caused by a clot or rupture of a blood vessel b) ischemic=clot - 85% of all strokes c) hemorrhagic=bleed - around brain - into brain
34
Dx of Carotid artery Dx
* Physical examination: carotid bruit * Suspicion leads to ultrasound of carotid arteries * Any abnormality on ultrasound: confirm with MRA or CT
35
Carotid artery Dz: Tx
•Lifestyle changes (no, seriously) - must stop smoking •Medications •Interventions
36
Two Major Goals in Treatment of PAD
1. Limb outcomes | 2. Cardiovascular morbidity and mortality outcomes
37
Two Major Goals in Treatment of PAD: | 1. Limb outcomes
``` • Improved ability to walk – Increase in peak walking distance – Improvement in quality- of-life (QoL) • Prevention of progression to CLI and amputation ```
38
Two Major Goals in Treatment of PAD: | Cardiovascular morbidity and mortality outcomes
* Decrease in morbidity from non-fatal MI and stroke | * Decrease in cardiovascular mortality from fatal MI and stroke
39
Tx to Improve CV Outcomes
Must treat the underlying causes! ``` • Smoking cessation • Anti-platelet therapy-aspirin • Hyperlipidemia (lifestyle and/or medications) -statin: 10mg & 80mg • Hypertension • Keep Diabetes under good control • Get active, lose weight ```
40
Considerations for the Treatment of Hypertension in PAD
* Blood pressure lowering is indicated to reduce the risk of stroke, MI, CHF, CRF, and death. * Individuals with PAD should receive hypertension treatment
41
Indications for Angioplasty/Stent
Indications Lower Extremities: – Persistent limiting claudication, preventing working and/or ADL – Rest pain – Tissue loss/non healing ulcers • Get the Patient walking, and they will start to heal themselves!! * Abdominal Aorta or Renal Arteries * Carotid Arteries *ADL: Activities of Daily Living
42
PAD and Surgery
• Lower extremity arterial disease: – Bypass (eg. Femoral to popliteal artery) – Vein or synthetic graft used • Abdominal Aorta – when the risk of rupture outweighs the risk of surgery - Normal aorta: 3cm or less - Aneurysm: 3-4-5 cm - At 5CM: risk of rupture>>>>surgery • Carotid Endarterectomy
43
In regards to PAD....smoking, physical inactivity, and DM increase:
– Prevalence of PAD – Presence of Asymptomatic disease – Risk of amputation, low quality of life
44
Dx modalities for PAD
– Doppler ultrasound to evaluate velocities – ABI/ pulse volume recordings – MRA, angiography
45
U/S Evaluation of Degree of Stenosis
• 50-79% stenosis – High systolic velocities, normal diastolic • 80-99% stenosis – Both systolic and diastolic velocities high • Occlusion – signal becomes similar to external carotid signal with low diastolic velocities
46
What does a carotid bruit mean?
* Asymptomatic bruits do increase stroke risk (14% over 5 years) - but not always on side of bruit * Good indicator of significant coronary disease (50-71%)
47
People risk for PAD
* Age: Less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia) * Age 50 - 69 years and history of smoking or diabetes * Age 70 years and older * Known atherosclerotic coronary, carotid, or renal artery disease

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