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Peripheral artery disease (PAD) Flashcards

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1
Q

Give a bunch of examples of peripheral vascular disease

A

Aortic aneurysm – abdominal
Aortic dissection - thoracic
AV malformation
Giant Cell Arteritis
PAD (peripheral artery disease)
RAS (renal artery stenosis)
Phlebitis/thrombophlebitis
Varicosities
Venous insufficiency
Venous thrombosis (DVT)

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2
Q

Define:
1) Aneurysm
2) Pseudoaneurysm
3) Dissection

A

1) Involves all three layers of aorta
2) Tunica intima and media
3) Tear in intima, dissects within media

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3
Q

What are the 3 layers of the arterial wall?

A

Intima
Media
Adventitia

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4
Q

Abdominal aortic aneurysms (AAAs):
1) What is it?
2) Who does it occur in?
3) Where do most occur?

A

1) Normal aorta diameter 1.8-2.0 CM; aortic aneurysm = > 3 CM
2) Men over age 55 y/o , M>W
3) Most occur below renal arteries (infrarenal AAA)

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5
Q

Describe the pathogenesis of AAAs

A

1) ASCVD, smoking, HTN, connective tissue d/o, trauma, syphilis
#1 risk factor is cigarette smoking
2) Thoracic and suprarenal occur: think Marfan’s, Ehlers-Danois, syphilis

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6
Q

1) What level divides thoracic and abdominal aortic aneurysms?
2) Which is less common?

A

1) T-12
2) Thoracic aneurysm ~ 10%

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7
Q

List risk factors for AAAs

A

1) Atherosclerosis CVD
2) 1st degree relative with AAA
3) PMHx of other aneurysms
4) Hypercholesterolemia
5) Hypertension
6) Male sex*
7) Obesity
8) Older age* > 65 y/o
9) Tobacco use*

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8
Q

Describe screening for AAAs according to the society of vascular surgeons

A

1) Aorta < 3.0 cm – no further screening
2) AAA: 3 – 3.9 cm – repeat in 3 years
3) AAA : 4 - 4.9 cm – repeat in 1 year
4) AAA: 5-5.4 CM – repeat in 6 months

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9
Q

Optimal surveillance schedule of AAA in patient _________________ is not well defined

A

not undergoing repair

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10
Q

USPSTF says what abt screening for AAA?

A

One time screen male, 65-75 y/o, ever smoked

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11
Q

What do asymptomatic AAAs usually mean?

A

Usually contained

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12
Q

Describe the symptomatic classic TRIAD for ruptured (high mortality rate) or contained AAAs

A

1) Hypotension or syncope (ruptured AAA)
2) Severe “tearing” abdominal pain radiating to back/flank
3) Tender Pulsatile abdominal mass, or bruit
Palpation of pulsatile mass at level of umbilicus
Bruit on abdominal auscultation (differ from renal bruit)

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13
Q

What are the Sxs of thoracic aortic aneurysms?

A

1) Chest pain, SOB, cough, hoarseness, or dysphagia
2) Aortic regurgitation

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14
Q

Describe how to diagnose AAAs

A

Imaging:
1) Stable – CT w/ contrast
2) Unstable – bedside US
3) CXR or abdominal x-ray
-Wide mediastinum
-Enlarged aortic knob
-calcifications

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15
Q

List 3 things you may see for AAAs on CXR or abdominal x-ray

A

1) Wide mediastinum
2) Enlarged aortic knob
3) Calcifications

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16
Q

Differentiate between imaging for stable and unstable AAA patients

A

1) Stable: CT w/ contrast
2) Unstable: bedside US

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17
Q

How do you Tx AAAS?

A

1) Optimize ASCVD risks
2) Smoking Cessation – best evidence to slow progression
5 A’s: Ask, Advise, Assess, Assist, and Arrange
3) Statins - clinical ASCVD = max tolerated statin group
4) Medications:
-B-blockers
-+/- ARBs
-Statins

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18
Q

What groups of meds should you Rx for AAAs?

A

-B-blockers
-+/- ARBs
-Statins

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19
Q

Describe the prognosis of emergent repair of ruptured AAAs

A

4-5% sudden death in USA
60-80% ruptured AAA do not reach Hospital
50% that survive to OR die

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20
Q

Aortic dissection:
1) Define this
2) What demographic is it common in?

A

1) Tear through intima, dissects into media and propagates longitudinally
-High likelihood of rupture
2) Age > 65 y/o; Men> women

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21
Q

List the clinical characteristics of Marfan’s syndrome

A

Tall – above average height
Long slender limbs – disproportionally
Scoliosis, thoracic lordosis
Pectus carinatum or pectus excavatum
Abnormal joint flexibility (Steinberg’s sign or thumb sign
High arched palate
Flat feet
Lens dislocation
Spontaneous pneumothorax

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22
Q

Differentiate type A and type B aortic dissections and their symptoms

A

1) Ascending thoracic aorta = Type A
-Anterior CP
2) Descending thoracic aorta = Type B
-Back pain

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23
Q

Aortic dissection:
1) What are the symptoms?
2) What are some PE findings?

Study These Flashcards
A

1) Acute severe tearing or ripping sensation radiating to back
-Diaphoresis, syncope, dyspnea, weakness
2) Hypotension, weak or absent pulse, BP variation, widening of pulse pressure, AR, neurologic deficit

24
Q

Describe the imaging for aortic dissection Dx if stable or unstable

Study These Flashcards
A

1) Stable: CT or MR angiography
2) Unstable: TEE
-CXR may show wide mediastinum, enlarged aortic knob, displaced trachea

25
What are the 2 goals of aortic dissection Tx? How are these accomplished?
1) Lower BP (lower to 90-110 systolic) -IV nitroprusside, BB, CCB 2) Lower velocity of LV ejection -IV esmolol (b-blocker)
26
Aortic dissection Tx 1) What should be given first? 2) Should you give pain control?
1) B-blocker 2) Yes, pain control
27
Aortic dissection Tx: Differentiate b/t type A and type B Tx
Emergent surgical consult: 1) Type A emergent sx repair 2) Type B medically manage initially
28
Peripheral artery disease: What are the 2 main categories? Describe
1) Chronic arterial occlusive disease 2) Critical leg ischemia A. chronic progressive B. acute thromboembolic
29
Differentiate between the causes of acute and chronic occlusion bc of artery disease
1) Chronic occlusion: due to ASCVD Intermittent claudication = leg pain with exertion Severe PAD = leg pain at rest 2) Acute occlusion: due to thromboembolism Critical limb ischemia
30
Differentiate between the 2 main categories of chronic occlusion [of artery disease]
Both due to ASCVD: 1) Intermittent claudication = leg pain with exertion 2) Severe PAD = leg pain at rest
31
Peripheral artery disease (PAD): What does it usually involve? Describe
Usually involves Aorta, external iliac arteries and distal: -Progressive ASCVD > Stenosis > Ischemia
32
List some risk factors for Peripheral artery disease (PAD)
Smoking, DM, age, CAD, HTN and dyslipidemia
33
List DDXs for chronic arterial occlusive disease
1) Spinal stenosis = pseudo claudication -Onset with activity; relieved with rest, sitting, or bending forward 2) Spinal cord tumors 3) Lumbar radiculopathy 4) DJD 5) DVT
34
List 3 different presentations of PAD
1) Intermittent claudication (stable angina) 2) Severe disease/ ischemia (unstable angina) 3) Aortoiliac disease
35
Describe the Intermittent claudication presentation of PAD
"Stable angina of the legs": 1) Pain/cramps with exercise 2) Relieved with rest
36
Describe the severe disease/ ischemia presentation of PAD
"Unstable angina of the legs": 1) Rest pain/cramps 2) Standing of hanging foot over the side of bed helps relieve pain
37
Describe the aortoiliac disease presentation of PAD
1) Claudication 2) Diminished or absent femoral pulses 3) ED [erectile dysfunction]
38
List the signs of PAD on physical exam
-Weak/absent pulses -Thin/shinny skin -Hair loss -Bruit -Muscular atrophy -Thick toenails -Cool skin temp -Ulcers: lateral malleolar ulcers
39
How do you Dx PAD? Explain
1) Ankle brachial index (ABI) 2) Systolic BP of posterior tibial artery(ankle)/Systolic BP of brachial artery(brachial) -Both arms; use higher number 3) Use bp cuff and doppler
40
Resting ABI: 1) What is abnormal? 2) What is borderline? 3) What is normal? 4) What is non-compress?
1) 1.40
41
Describe claudication mgmt
1) Risk factor modification (HTN, DM, Chol, smoking cessation) 2) Mild to moderate symptoms Exercise PAD directed drug therapy – antiplatelets, cilostazol Symptoms improved – continue/monitor Symptoms worsen (or critical limb ischemia) - localize lesion only if considering revascularization – MRA, conventional angiography –
42
Severe PAD/critical limb ischemia: Describe progression of disease
Pain at rest in foot and toes – may be reported as numbness or tingling Worse with legs elevated, relieved with legs dependent Leg edema Hair loss, smooth shinny skin Pallor with legs elevated Rubor with legs dependent Bruits, decreased pulses Cyanosis, ulceration, gangrene
43
PAD: acute arterial occlusion 1) What is its origin? 2) What is the most common source? Give examples
1) Thromboembolic 2) Heart is most common source: 80-90% A. Fib PFO/ASD IE/VHD
44
PAD; acute arterial occlusion: What are the 6 Ps of presentation?
Pain Pallor Paresthesia Pulselessness Poikilothermia Paralysis
45
PAD; acute arterial occlusion: Where do emboli lodge?
1) Lower extremity at bifurcations 65-70% 2) Cerebral arteries: 20-25% 3) Upper extremities: 5-10% 4) Visceral arteries: 5-10% Acute SMA artery occlusion Pain out of proportion to PE findings
46
Describe how to Dx acute arterial occlusion (type of PAD)
Arterial doppler exam CT or catheter based Angiography Source: EKG looking for MI, A. Fib Echo evaluation for clot, valve or wall dysfunction
47
How do you Tx acute arterial occlusion?
1) Anticoagulate with IV heparin bolus/infusion or enoxaparin (Lovenox) 2) Emergent re-vascularization: angioplasty/stent, embolectomy thrombolysis, bypass
48
Give the intermittent claudication, severe/critical limb ischemia, acute thromboembolism BLUF
Optimize risk factors (smoking cessation) and medical management of Lipids, BP, blood glucose Supervised or home graduated exercise program Foot care (just like diabetic foot care) Medical: antiplatelet inhibitors - ASA or Clopidogrel or Cilostazol (Pletal)- Revascularization Reasonable option in patients with lifestyle-limiting claudication and inadequate response to guideline directed therapies Indicated for patients with critical limb ischemia Emergent in patients with acute limb ischemia
49
Raynaud’s (ray nose) phenomenon: 1) What is it? 2) What is primary? 3) What is secondary?
1) Recurrent vasospasm of the finger/toes/tip of nose in response to stress or cold exposure 2) Primary: idiopathic – no underlying disease 3) Secondary: associated with other diseases
50
Give and describe 2 examples of secondary Raynaud's phenomenon
1) Rheumatic -Progressive systemic sclerosis/scleroderma -Mixed connective tissue disease, SLE -Dermatomyositis, Sjogren’s 2) Hematologic -Cryoglobulins -Paraneoplastic syndromes
51
Buerger disease (aka thromboangiitis obliterans): 1) What is it? 2) What does it lead to? 3) Where is it usually seen first?
1) Disease of the arteries and veins resulting in occlusion from blood clots 2) Ischemia leads to tissue damage, necrosis, gangrene. 3) Buerger disease is usually first seen in the feet, then hands, and progress proximally in the extremities … amputations
52
Buerger disease (aka thromboangiitis obliterans): 1) What are 2 risk factors? 2) What is the Tx?
1) Male, tobacco use (all forms) 2) Tobacco cessation is the only way to stop Buerger disease
53
Giant cell arteritis (GCA): 1) What is it? 2) What is a common Sx?
1) Immune mediated inflammatory disease of large and medium arteries of the head 2) 3/4 pts have a headache
54
GCA: 1) What is the general Tx? 2) What abt without visual loss? 3) What abt with?
1) Treatment is high dose corticosteroids 2) Without visual loss at presentation: prednisone 1 mg/kg or equivalent, not to exceed 60 mg, given in a single daily dose x 4 weeks, taper slowly and maintain for 1-2 years 3) With threatened or established visual loss at presentation:  methylprednisolone 500 to 1000 mg intravenous daily x 3 days then transition to PO prednisone as above
55

(PA School) Cardiology (62 decks)

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