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Flashcards in PAD & Acute Limb Ischemia Deck (16):
1

PAD - Peripheral Arterial Disease
PATIENT HISTORY:
1. What is it caused by?
2. Signs/ Symptoms?
3. Anything that makes it worse/better?

1. intermittent claudication
- atherosclerotic lesions in the limbs, which diminish blood supply to the muscles of the lower leg
2. pain, cramping, and weakness in the calf muscles of one or both lower limbs
3. Relieved by rest.. worse during exertion

2

PAD- Peripheral Arterial Disease
Clinical features: define the first symptom of peripheral disease?
1. what are the common features found?
2.waht is specific to the iliac artery?
3. What does severe, chronic PAD disease result in?
4. What do the symptoms depend on?
5. What does extremity occlusion usually result in?

definition = lower leg pain with exercise, which is relieved by rest (INTERMITTENT CLAUDICATION), later pain at rest occurs
-Femoral and distal pulses will be weak or absent; hair loss, thin shiny skin, muscle atrophy
-aortic, iliac, or femoral BRUIT may be present
- erectile dysfunction occurs with iliac artery disease (Leriche's syndrome)
-severe, chronic disease results in numbness, tingling, and ischemic ulcerations, which may lead to gangrene
-symtoms of occlusion depend on the artery, where it supplies, and collateral circulation
-extremity occlusion usually results in pain, pallor, pulselessness, paresthesias, poikilothermia, and paralysis
paresthesias = skin sensation; burning, prickling, itching, or tingling, with no apparent physical cause
Poikilothermia = cold blooded?
paralysis = complete loss of strength in an affected limb or muscle group

3

Calf pain is the HALLMARK of what?

Femoral-popliteal disease

4

Describe aortoiliac disease?

Leriche Syndrome
discomfort in the thigh, hip, or buttock w/ impotence (erectile dysfunction)

5

Differentiate Pseudoclaudication of lumbar degenerative spinal canal stenosis and PAD

Pseudoclaudicatin of lumbar…
walking can aggravate leg pain, but is NOT relieved by rest
stooping forward or sitting alleviates the pain (assuming positions that minimize lumbar extension)
*unilateral limb discomfort = pseudoclaudication - caused by spinal nerve

6

Laboratory Findings of PAD
1a. define the most used diagnostic test?
1b. what are the normal and abnormal findings?
1c. what can cause a false negative result?

2. what is used to determine systolic pressures in the posterior tibial and dorsalis pedis arteries (BLOOD FLOW)?

3a. what is used for locating stenotic sites and identification of "run off vessels"?
3b.what is it used for accurate DIAGNOSIS OF?

4. What is the "GOLD STANDARD" reserved for patients undergoing revascularization?

1a. Ankle-Brachial Index (ABI) = ratio highest readings of BP at dorsal is pedis or posterior tibialis artery to brachial artery
1b. normal = 0.9 to 1.3 ; abnormal = 0.9 = PAD
1c. calcification of vessels seen with DM and renal failure may cause false negative results

2. Doppler Ultrasound -
- notes = useful to diagnose patients with calcification (non-compressible vessels)

3a. CT or magnetic resonance angiography
3b. used for accurate diagnosis of thrombosis or embolism

4. Catheter-based angiography

7

Medical Treatment:
1. lifestyle changes?
2. main drug treatment = drug that is one of the most effective agents for intermittent claudcation? with what?
3. patient with aorticilliac disease?
4. when do you use percutaneous revascularization?
5. when do you use surgery?

1. STOP SMOKING!! , progressive exercise, lipid lowering meds reduces the risk for new onset or worsening claudication.
2. CILOSTAZOL w/ antiplatelet therapy (asprin and clopidogrel)
3. Sildenafil - (phosphodiesterase V inhibitor)
4. distal aorta or iliac arteries
5. longer areas of stenos or obstructive lesions distal to the origin of the iliac arteries

8

patient with PAD has a LDL above 100 ..
1. what do you prescribe?
1. what are the side effects?
1. contradictions?

1. HMC-CoA reductase Inhibitor (STATIN)
major side effects = myopathy and increased liver enzymes
contradictions = absolue: liver disease

9

Patient with PAD -
prescribe bp lowering therapy until BP is less than _____?
in patins with diabetes, previous MI, left ventricular hypertrophy by EKG or echo, or chronic renal disease prescribe BP lowering therapy until BP is less than ______?

1. less than 140/90
2. less than 130/80

left ventricular hypertrophy:
on EKG =
on Echo =

10

What is a MAJOR RISK associated with INTERMITTENT CLAUDICATION?

10 year risk for morbidity and mortality

11

what are the 4 major risk factors for PAD?

1. SMOKING
2. diabetes mellitus
3. Hyperlipidemia
4. HTN (hypertension)

12

Are men or women more prevalent to PAD?
is PAD associated with age?

MEN
prevalence increases with age
20-30% > 70
2-6% <60
so the rest are between 60-70 yrs old?

13

we know that Cilostazol is the MAIN THERAPY used for PAD!
1. what is its mechanism of action?
2. what does it improve?
3. what pt should it be avoided in?

1. phosphodiesterase III inhibitor
2. Improved walking capacity & quality of life
3. avoid in pts with CHF due to increased mortality

14

VASCULAR EMERGENCY:
Acute Arterial Occlusion may be caused by thrombosis or embolism.
what is the hx of each?
what are the symptoms of each?

1. Arterial emboli = originate in cardiac chambers with preexisting cardiac diseases such as MI, CHF, or arterial arrhythmias;
--symptoms = sudden onset of pain w/o hx of claudication

2. Thrombosis in situ = usually occurs in arteries w/ preexisting severe stenosis in the setting of longstanding PAD w/ or without previous vascular surgery
--symptoms = Hx of claudication that has previously been stable & Suddenly assumes a CRESCENDO pattern over a period of days

15

Physical exam of Acute Arterial Occlusion =
What confirms the dx?

cold, cyanotic extremity
absence of pulses distal to occlusion
diminished motor or sensory function
Hand held doppler device confirms dx

16

What is the treatment of Acute Arterial Occulsions?
1. what is used to maintain the activated PTT of 2.0 to 2.5?
2. patient with symptoms longer than 14 days and suprainguinal occlusion?
3. More recent onset of symptoms and infrainguinal occlusion?
4. irreversible tissue necrosis?

1. immediate anticoagulant therapy with IV HEPARIN
2. thromboembolectomy or bypass surgery
3. thrombolytic therapy ; percutaneous thrombosis extraction
4. emergent amputation rather than revascularization to reduce risk of kidney failure, sepsis, & multi organ failure