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Cardiology > Peripheral Vascular Disease > Flashcards

Peripheral Vascular Disease Flashcards

1
Q

Name some examples of Arterial Disease (PAD)

A

Atherosclerotic Occlusive Disease (Chronic Arterial Insufficiency, Acute Arterial Insufficiency), Thromboangiitis Obliterans (Buerger’s disease)

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2
Q

Name some examples of Venous Disease

A

Varicose veins
Chronic Venous Insufficiency
Superficial Thrombophlebitis
Deep Vein Thrombosis

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3
Q

What is amaurosis fugax?

A

A symptom of carotid artery disease. Occurs when a piece of plaque in one of these arteries breaks off and travels to an artery in the eye causing loss of vision from temporary lack of blood flow to the retina. It may be a sign of impending stroke

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4
Q

What is Chronic Arterial Insufficiency (CAI)?

A
  • Chronic, progressive disease caused by atherosclerosis
  • Causes obstruction or stenosis of large or medium sized vessels primarily in the lower extremities
  • Blood flow to active muscles is limited resulting in intermittent claudication
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5
Q

What can intermittent claudication indicate?

A

Chronic Arterial Insufficiency

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6
Q

What is intermittent claudication?

A

Pain in low back/buttock, thigh, foot, or calf that occurs after walking a constant distance-worse with incline or load

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7
Q

Describe the location of pain during intermittent claudication and what it means in terms of what vessels are affected

A

Low back/buttock=aortoiliac
Thigh=iliac or common femoral artery
Foot=at or below the popliteal artery
Calf= any vascular level or superficial femoral artery

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8
Q

Name some signs/symptoms of patient with Chronic Arterial Insufficiency

A
  • Limbs may appear normal, or may have global atrophy
  • Sparse or absent hair over lower legs and toes
  • Dusky rubor on dependency (NOT erythema!)
  • Ulcerations of areas of gangrene distally
  • Diminished or absent pulses
  • Cool extremities (dorsal side of hand from distal to proximal-compare bilaterally)
  • Thickened nails
  • Delayed capillary refill
  • pallor of foot on elevation
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9
Q

Describe ulcers related to Chronic Arterial Insufficiency.

A

Location: Toes, feet, or possibly areas of trauma

Skin Around Ulcer: No callus or excess of pigment; may be atrophic

Pain: Often severe unless masked by neuropathy
Associated gangrene may be present

Associated signs: Decreased pulses, trophic changes, pallor of the foot on elevation, dusky rubor on dependency

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10
Q

What is an Ankle Brachial Index? What is the purpose of a ABI?

A

Bedside test comparing upper and lower extremity blood pressures to determine if CAI is present

Ratio of systolic blood pressure at the ankle divided by that of the arm; Level above 0.9 is normal; Level of <0.5 indicates significant disease. Very low may indicate need for amputation

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11
Q

List risk factor modification for patients with Chronic Arterial Insufficiency

A
  • Tobacco Cessation
  • Aggressive management of lipid disorder, glycemic disorders and hypertension
  • Exercise Regimen
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12
Q

Pharmacologic Management of Chronic Arterial Insufficiency?

A

Aimed at symptomatic relief or slowing natural progression of disease

Antiplatelet agents–> no improvement or modest improvement in claudication symptoms

Antiplatelet Agents (Aspirin, Clopridogrel)
Rheologic modifier (Pentoxifylline)
Phosphodiesterase inhibitor (Cilostazol)
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13
Q

How does Pentoxifylline work?

A

Decreases blood viscosity, platelet adhesiveness and fibrinogen concentration. Evidence for benefit in Chronic arterial Insufficiency is marginal

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14
Q

How does Cilostazol (Pletal) work?

A

Suppresses platelet aggregation and works as a direct arterial vasodilator

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15
Q

What are the 5 P’s of Compartment Syndrome?

A 
Pain
Pallor 
Parasthesias
Pulselessness
Paralysis
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16
Q

Ticlodipine is similar to clopridogrel but is thought to be less safe due to what reasons?

A

luekopenia and thrombocytopenia risk

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17
Q

Patient Education for patient with Chronic Arterial Insufficiency?

A
  • Check feet regularly
  • Keep feet warm and dry
  • Avoid extremes in temperature
  • Inspect for injuries-report bruises or cuts immediately
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18
Q

What is Acute Arterial Insufficiency?

A

Loss of arterial blood supply to the distal extremities, usually due to acute thrombus formation of a diseased blood vessel (i.e.a ruptured plaque) or the blockage of a vessel by an embolus from another location (Embolic or Throbotic–your job to figure out!!!)

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19
Q

What are the two common presentations of Acute Arterial Insufficiency?

A
  • 50% Sudden onset of severe, unrelenting leg pain

- 50% have insidious onset of pain in the affected extremity over several hours

20
Q

What are the signs and symptoms of an Arterial Emboli?

A
  • Area distal to the occlusion is cold, pale and pulseless
  • Veins are collapsed and muscles may be tender
  • Manifestations are usually sharply demarcated (e.g. lower 1/3 of the thigh in femoral artery embolus)
21
Q

What is atheroembolism? Name an example of this.

A

Cholesterol emboli triggered by invasive arterial procedures such as cardiac catheterization.

Example: “Blue toe syndrome”

22
Q

What are the signs and symptoms of Acute Arterial Thrombosis?

A
  • Absence of pulses in the affected extremity
  • History of intermittent claudication
  • Absence of a source of emboli
23
Q

Describe management for Acute Arterial Insufficiency?

A
  • Hospitalization and urgent vascular consult
  • Thrombolytic therapy (streptokinase or tissue plasminogen activator-TPA) or anticoagulation with heparin
  • Limb placed in a dependent position and kept warm
  • Adequate analgesia
  • Conservative treatment, embolectomy, angioplasty, arterial bypass are possible choices based on degree of involvement
  • Amputation may be required if arterial blood supply is not reinitiated quickly
24
Q

What is another name for Thromboangiitis Obliterans?

A

Buerger’s Disease

25
Q

What is Thromboangiitis Obliterans?

A

-Occlusive inflammatory disease of distal small to medium arteries of the upper and lower extremities

26
Q

Who may be affected by Thromboangiitis Obliterans?

A
  • Prevalence higher in Japan, India, Southeast Asia compared to US
  • Rare in women-seen most commonly in men who smoke
  • Not associated with other atherosclerotic risk factors
27
Q

What are the signs and symptoms of Thromboangiitis Obliterans?

A
  • parasthesias, coldness, skin ulcers, gangrene, claudication
  • prolonged capillary refill, dependent rubor, or necrotic skin ulcers at tips of digits
28
Q

Treatment of Thromboangiitis Obliterans?

A
  • Smoking cessation is MANDATORY to prevent need for amputation
  • Refer for vascular surgical consult
29
Q

What are varicose veins?

A
  • Inherited defect resulting in venous valve incompetence
  • Poor valve function causes high venous pressure in the lower extremity with stasis and pooling of blood
  • Increased pressure creates stretching and distention of veins
  • Highest incidence in women who have been pregnant; standing and lifting are contributing factors
30
Q

Signs & Symptoms of Varicose Veins

A
  • Fatigue or dull aching pain in the leg that may be worse with standing
  • Many are asymptomatic until disease progresses
  • Many have visible, dilated veins
31
Q

What is the Trendelenburg Test?

A

A test that distinguishes superficial venous insufficiency secondary to saphenofemoral valve incompetence from perforator vein incompetence

32
Q

Describe the Trendelenburg Test used with regards to Varicose Veins

A

Elevate leg-compress saphenous vein manually. Have patient stand while maintaining compression.

If varicosities are due to saphenous femoral valve dysfunction/insufficiency, the varicosities will remain flat when patient stands

If varicosities are due to perforator incompetence varicosities will become immediately apparent-normally it takes about 35 seconds to fill from below

Release compression-sudden additional filling indicates incompetent valves in the superficial veins

33
Q

What is the medical management of Varicose Veins?

A

-Frequent elevation of legs
weight loss
-Surgical measures-escisions of varicosities
-Sclerotherapy-injection of sclerosing agent followed by compresion
-Compression Stockings

34
Q

What is Superficial Thrombophlebitis?

A

Partial or complete obstruction of superficial vein by a thrombus; May occur spontaneously or be associated with injury, may be initial manifestation of an abdominal cancer such as pancreatic cancer (Trousseau’s Sign)

35
Q

What is Virchow’s Triad?

A

stasis, hypercoaguability and vessel damage = increased risk of developing phlebitis

36
Q

Signs & Symptoms of Superficial Thrombophlebitis?

A
  • Dull pain over vein
  • Induration and erythema, often a linear pattern along the path of superficial vein
  • Vein may be cord like
  • May be localized or involve a length of the saphenous vein and its tributaries
37
Q

Management of Superficial Thrombophlebitis?

A
  • Bed rest, local heat, elevation
  • NSAIDS
  • If progressive of infectious, saphenous vein may require surgical removal
  • Coverage for staphylococcus pending results of blood cultures
  • Inflammation usually subsides in 1-2 weeks
  • Increases likelihood of developing post-phlebitic syndrome
38
Q

What is Chronic Venous Insufficiency (Postphlebetic Syndrome)?

A

Chronically swollen limb associated with stasis dermatitis, subcutaneous tissue induration and ulcerations; appears after phlebitis and is associated with incompetent superficial or deep veins

39
Q

List some signs and symptoms of Chronic Venous Insufficiency

A
  • Stasis dermatitis (skin with brown pigmentation; itchy scaly rash around medial malleolus is hallmark finding; Edema progresses from pitting to induration)
  • Ulcerations due to tissue hypoxia caused by inflammation and stasis of blood
40
Q

What does a venogram show in a patient who has Chronic Venous Insufficiency?

A

Feathery appearance of the lining of veins (indicates previous phlebitis)

41
Q

What are some risk factors for DVTs

A
  • Immobilization
  • Illnesses involving bed rest
  • Use of oral contraceptives
  • Hypercoaguable states
  • Obesity
  • Previous history of DVT
42
Q

Signs and Symptoms of DVT?

A
  • May be asymptomatic in early stages
  • Dull ache to frank pain in calf (Positive Homan’s sign!), or buttocks
  • Slight edema
  • Distention of superficial collaterals
  • Slight fever
  • Tachycardia
  • Cyanosis if venous obstruction is marked
43
Q

What lab might be used during work-up of DVT?

A

plasma levels of fibrin D-dimer (increased plasma levels generated from crosslinked fibrin which indicates recent/ongoing coagulation

44
Q

What is the gold standard diagnostic test used to diagnose a DVT?

A

Venography is best at defining the location and extent of disease but is expensive, uncomfortable, and associated with risks- seldom used for screening

45
Q

What are the requirements for outpatient management of a patient with a DVT?

A

Age <75, not at risk for bleeding or recurrent clot formation, no sx of PE and adequate cardiopulmonary reserve if PE possible

46
Q

What is the exclusion criteria for outpatient management of a DVT?

A

Pregnancy, allergy to heparin, non-adherence or risk of loss to follow-up, history of stroke in past 6 weeks, hemoglobin <7 g/dL, non-cutanous surgery in past 2 weeks, s/sx of PE or poor cardiopulmonary reserve

Cardiology (8 decks)

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