Peripheral Vascular Disease Flashcards by Courtney Birkett

What is the most common underlying cause of peripheral arterial disease?

Atherosclerosis (narrowing of arterial lumen that reduces blood flow to limb)

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What is the progression of peripheral arterial disease?

Asymptomatic stenosis
Chronic arterial insufficiency
Limb-threatening ischemia (can be sudden tho)

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What is important to know about PAD and mortality?

PAD is a powerful, independent predictor of mortality

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What are fatty streaks in atherosclerosis?

Thickened intima and accumulation of foam cells

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Where do plaques commonly occur?

Bifurcations: aortic, iliac, femoral

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Important risk factors for atherosclerosis/PAD

Hypertension, diabetes, dyslipidemia/hyperlipidemia, smoking

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Acute vs chronic limb ischemia

Acute: sudden decrease in limb perfusion, potential threat to limb viability
Chronic: pts who present later than 2 wks after onset of acute event

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Where do most pts with PAD have athersclerosis?

Lower extremity

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Groups at risk for PAD

Over 70
50-69 with hx of smoking/diabetes
40-49 with diabetes and one other risk factor for atherosclerosis
Leg sxs: claudication or ischemia pain at rest
Known atherosclerosis at other sites

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Diabetes and amputation

Dose-response relationship between HgbA1c level and risk of amputation

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What is claudication?

Intermittent discomfort (cramps,aches) in defined muscle group, induced by exercise and relieved with rest
Calf, thigh or buttock

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What is Leriche syndrome?

Claudication (buttock, hip, thigh)
Absent/diminished femoral pulses
ED

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What is the site of stenosis for each claudication sx?
Buttock/hip
Thigh
Upper 2/3 calf
Lower 1/3 calf
Foot

Aortoiliac disease (Leriche)
Aortoiliac disease/common femoral artery
Superficial femoral artery
Popliteal artery
Tibial or peroneal artery

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What is critical limb ischemia?

When blood flow is insufficient to meet demands at rest
Threatened limb!
73-95% limb loss or death at one yr without tx
Time sensitive!!!

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Presentation of critical limb ischemia

Ischemia rest pain: pain in forefoot/toes aggravated by elevation and relieved by dependency
Non-healing wounds/ulcers
Skin discoloration/gangrene (pale elevated and red lower)

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What is the ankle-brachial index?

Ratio of ankle SBP divided by highest brachial SBP

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When do you perform the ankle brachial index?

Lower extremity exertional sxs
Risk factors for PAD
ABI

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What is an arterial duplex doppler ultrasound?

Reflected sound wave frequency is used to determine velocity of blood flow
Can find the site and severity of vascular obstruction (% stenosis)

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What is the gold standard for diagnosis of PAD?

Vascular imaging: contrast arteriography (angiogram)

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What are the lifestyle modifications and risk factor reductions for PAD?

Antiplatelet therapy (ASA or Plavix)
Smoking cessation
Lipid lowering therapy (moderate dose statin)
Control blood sugar and BP
Weight management

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Tx for claudication sxs of PAD

Supervised exercise (30-45 min 3xwk for 12 wks)
Cilostazol (Pletal): phosphdiestase inhibitor, antiplatelet and vasodilator effects

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What is the first line tx for revascularization of PAD?

Endovascular in critical limb ischemia

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What are the endovascular interventional procedures?

Percutaneous transluminal angioplasty, stents, atherectomy

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Most common bypass graft

Femoral-popliteal

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What is the most common cause of acute arterial occlusion?

Thromboembolism (majority originate in heart) | Others (sudden thrombotic occlusion of narrowed segment, atheroembolic debris, arterial dissection)

Sxs of acute arterial occlusion

``` 6 Ps (usually in this order too) Paresthesia Pain (located distal and progress proximal) Pallor Pulselessness Poikilothermia Paralysis ```

Management of acute arterial occlusion

``` Emergency surgical consult Anticoagulation with heparin Thrombolytics- intrarterial Thromectomy/ embolectomy Surgical bypass Amputation in 25-30% ```

Most common things seen chronic venous disease

Telangiectasias, varicose veins, chronic venous insufficiency Higher in women than men

What causes chronic venous disease?

Venous hypertension (dysfunction of venous valves, obstruction to venous flow, failure of venous pump)

What veins are affected in chronic venous disease?

Usually superficial ones

Main presentation of chronic venous disease

May be asymptomatic but aching. heaviness or burning sensation that is worse with standing and relieved by elevation

What causes chronic venous insufficiency?

Valvular incompetence or result of DVT with residual damage to vein (recanalization after DVT) Rigid and thick-walled veins

What are more advanced clinical signs of chronic venous insufficiency?

Significant edema, skin changes, ulcerations

What is hemosiderin staining?

Seen in chronic venous insufficiency | Pigmented byproduct of Hb

What is lipodermatosclerosis

Seen in chronic venous insufficiency Inflammation of layer of fat under epidermis, subQ fibrosis and hardening of skin Looks like champagne bottle

What can you find with venous duplex dopple u/s?

Valve insufficiency, chronic vein wall thickening, chronic thrombosis

What is the gold standard to diagnose chronic venous insufficiency?

Venography

What do you see in stasis dermatitis?

Erythema, inflammation, pruritus, scaling and vesicle formation (mostly medial ankle) Use emollients, barrier creams or topical corticosteroid

Management of chronic venous disease

Exercise, weight loss, mechanical, compression therapy, wound care Meds (diuretics for edema, abx), radiofrequency or lase, sclerotherapy for small surface veins, vein stripping or skin grafts

When is compression therapy contraindicated?

Moderate to severe PAD, cellulitis and acute DVT

What is the most common cause of aortic aneurysms?

Atherosclerosis | Also connective tissue disease (marfans, ehlers-danlos), infection, trauma

Common presentation of aortic disease

Severe, persistent chest pain, syncope, CVA-like sxs, altered mental status, paresthesia Hypertensive usually, dimished or unequal peripheral pulses, horner's syndrome

Test of choice for dx of aortic dissection

CT chest and abdomen (CXR can be used to show widened mediastinum but not test of choice)

First line treatment of aortic dissection

True emergency! Immediate control of BP with beta-blockers (labetalol)

Most common sxs of thoracic aortic aneurysm

Most are asymptomatic | May have back pain, dysnpea, stridor, edema in neck and arms, distended neck veins, hoarseness

Diagnostic test of choice for thoracic aortic aneurysm

CT scan (ONLY IF STABLE)

Most common site of abdominal aortic aneurysm

Infrarenal abdominal aorta

What can an AAA lead to?

Rupture or dissection, thromboembolism, compromised renal blood flow

When can you feel the AAA in 80% of pts?

Over 5 cm

Sxs of abdominal aortic rupture

Excruciating abdominal pain that radiates to back, pulsatile mass, tenderness, hypotension

What is the diagnostic study of choice for screening of AAA?

Abdominal u/s | CT scan is more reliable tho and should be used when the diameter is closer to 5.5 cm

What is the age you look at for screening for AAA?

65-75 (all current or past smokers or have relative with AAA)

Management of AAA

Risk factor modification, watchful waiting (routine u/s), refer to vascular specialist

What types of repair can you do for AAA?

Endovascular repair or open surgical resection

Sxs of carotid artery stenosis

TIAs Focal neuro sxs (amaurosis fugax which is transient monocular blindness or contralateral weakness/numbness, dysarthria or aphasia)

What might you see on a PE in carotid artery stenosis?

Bruits, absent pupillary light response, arterial occlusion or ischemic damage to retina

What is a Hollenhorst plaque?

Cholesterol embolus in retinal vessel

What is the first test dx of carotid artery stenosis and what is the gold standard?

Carotid duplex u/s (very sensitive and specific) | Cerebral angiography is standard but rarely performed

What are some risk equivalents for coronary heart disease?

PAD or carotid artery stenosis

Tx for symptomatic carotid artery stenosis

Revascularization by carotid endarterectomy or carotid artery stenting

Peripheral Vascular Disease Flashcards

(60 cards)