Commonly result of atherosclerosis
Significant independent risk factor for cardiovascular / cerebrovascular morbidity/mortality
Initially asymptomatic, but typically progresses to claudication, ischemia, pain with exercise in lower extremities.
Peripheral Arterial Disease
Critical progression of PAD
Acute limb ischemia: pain at rest, skin ulceration, gangrene, loss of limb
Numbness, tingling
What may cause an acute progression of PAD
Arterial Thrombosis / embolism
Commonly the first symptom of PAD
Intermittent claudication
(Foot or lower leg pain with exercise, relieved by rest)
thigh or buttock pain may occur
How might PAD affect pulses?
- Femoral and distal pulses weak or absent
2. Aortic, iliac, femoral bruit may be present
Skin changes caused by PAD
Hair loss
Shiny atrophic skin
Pallor with dependent rubor
Pain, pallor, lack of pulse, paresthesias, poikilothermia, paralysis : INDICATE WHAT
Acute arterial occlusion
Highly sensitive and specific test for PAD
Ankle-brachial Index (ABI)
ABI <0.9 is diagnostic
ABI 1.00 + is normal
“Gold Standard” study
Angiography
Test used for locating stenotic sites and for accurate diagnosis of thrombosis or embolism - not used routinely, only to prepare for revascularization
CT or MRI
Test used to determine systolic pressures in peripheral arteries
Doppler ultrasound flow studies
PAD treatment
Aggressive risk factor modification
- tobacco use, diabetes, HTN, hyperlipidemia
Aspirin and/or clopidogrel
Beta blockers / ACE inhibitors, Statins
Exercise
Highest prevalence of atherosclerotic PAD in what age range
60-70 years
Primary sites of involvement for PAD
- Femoral and popliteal (80-90%)
* *elderly and diabetic patients** - Tibial and peroneal arteries (40-50%)
- Aortic and iliac (30%)
* lesions often occur at branch points - due to increased turbulence*
T/F - Most patients with PAD are symptomatic?
False - fewer than 50% are symptomatic
though many have slow or impaired gait
What test is used to image and detect stenotic lesions, routinely?
Duplex utlrasonography
Condition that develops from superficial venous insufficiency and valvular incompetence.
Varicose Veins
Occurs in approx 15% of adults, esp women
Treatment for Varicose Veins
- Graduated elastic stockings
- Leg elevation / regular exercise
- Unna boot (compression boot dressing) for ulcers
Virchow’s triad for assessing risk of developing thrombophlebitis
Stasis, vascular injury, hypercoaguability
Often occurs at site of IV or PICC lines
Superficial thrombophlebitis
Associated with surgical procedures, prolonged bed rest, lower extremity trauma, oral contraceptives
DVT
Presents with dull pain, erythema, tenderness, and sometimes induration of involved vein, or no symptoms
DVT
Most common vein involved w DVT
Long saphenous vein
Percentage of patients that present DVT with no symptoms
50%
Classic findings of DVT
swelling of involved area, heat and redness over the site
Preferred study for DVT
Duplex ultrasonography
neg duplex results in patients with high suspicion warrants further testing
Most accurate method for definitive diagnosis of DVT, but associated with increased risk and rarely indicated
Venography
How can a D-Dimer be used?
To RULE OUT - a negative D-Dimer suggests ultrasonography may be omitted
(D-dimers are elevated in a number of conditions - most hospitalized patients have elevated d-dimers)
Study if PE is suspected?
CT angiography is study of choice
(Pulm angiography is “gold standard” but rarely performed)
V/Q scan can be used if CT contraindicated
Treatment for superficial thrombophlebitis
Conservative!
- Best rest, local heat, elevation
- NSAIDs
- Antibiotics IF evidence of infection exists
Preventing DVT in bed ridden patients
Elevation of foot
Leg exercises
Compression stockings / devices
Anticoagulants (Heparin) in high risk patients
Characterized by loss of wall tension in veins, resulting in stasis of venous blood. Often associated with history of DVT, leg injury, varicose veins
Chronic Venous Insufficiency
Progressive edema starting at the ankle. Itching, dull pain with standing, ulceration
Chronic Veinous Insufficiency
Where are ulcers most commonly found in chronic veinous insufficiency?
Just above the ankle (stasis ulcer)
Skin changes in chronic veinous insufficiency
Skin is shiny, thin, atrophic
Dark pigmentary changes and subcutaneous induration
Treatment of stasis dermatitis in chronic venous insufficiency
- Wet compresses
- Hydrocortisone cream
- Zinc oxide
- Antifungal cream when indicated
Systemic inflammatory condition of medium and large vessels. Frequently coexists with polmyalgia rheumatica.
Giant cell arteritis
Arteries frequently involved with giant cell arteritis?
Temporal Artery
and other extra cranial branches of carotid artery
What can giant cell arteritis lead to if not treated aggressively?
BLINDNESS
Within 7 years, what can occur in 15% of patients?
Large vessel problems (e.g. thoracic aortic aneurysm)
Patients are typically elderly and complain of unilateral temporal headache
giant cell arteritis
Additional signs and symptoms of giant cell arteritis
Scalp tenderness, jaw claudication, throat pain, diplopia, elevated inflammatory markers
Polymyalgia rheumatica occurs in 50% of patients: pain and stiffness of shoulder and pelvic girdle
Definitive diagnosis for giant cell arteritis
Temporal artery biopsy
Test indicating a temporal artery biopsy may be necessary
History / symptomology +
SED and CRP highly elevated
Hematologic finding often associated with giant cell arteritis
Normochromic normocytic anemia and thrombocytosis
Treatment for giant cell arteritis
High-dose prednisone for 1-2 months and low-dose aspirin.
initiated immediately, not to wait to biopsy results
Weakness and subsequent dilation of the vessel wall, usually caused by atherosclerotic damage to the intima
Aorta aneurysm
Genetic causes of aortic aneurysm
Marfan’s, Ehlers-Danlos syndrome
Classic picture of patient with aortic aneurysm
Eldery male smoker with CAD, emphysema, and renal impairment
men are 8x more likely to have aneurysm
Mortality rate for rupture of aortic aneurism (dissection)
90%
Substernal, back, or neck pain. Dyspnea, stridor and cough. Dysphagia. hoarseness. Superior vena cava syndrome.
Thoracic aorta aneurysm
Severe pain, “ripping” or “tearing” chest pain radiating to the back
Thoracic aortic dissection
Severe back, abdominal, flank pain. Hypotension and shock
Abdominal Aortic Aneurism Rupture
25% of patients with aortic aneurysms present with these diseases
Renal or lower extremity occlusive disease
Study of choice for abdominal aneurysms
Abdominal ultrasonography
Screening protocol for abdominal aneurysms
Single abdominal ultrasound for men older than 65 yrs who have ever smoked
Diagnosing thoracic aneurysms
May require aortography
CT/MRI prefered over ultrasonography
Occurrence of abdominal vs thoracic aortic aneurysms
90% abdominal
10% thoracic