Peripheral Artery Disease

definition of PAD

inability of the vessel to carry oxygenated blood to the target organ

3 main types of arterial disease

atherosclerosis

dissection

aneurysm

atheromatous plaques in the lumen due to damage to the endothelium

atherosclerosis

preferred sites of atherosclerosis

vessel bifurcations

prevalence of PAD increases with _

age

demographic more prone to PAD

african american males

7 risk amplifiers of PAD

older age

diabetes

tobacco use

CKD

polyvascular disease

microvascular disease

depresion

progressive atherosclerotic disease leads to _

ischemia

when do symptoms of PAD become pronounced

once lesions are hemodynamically significant

why do symptoms occur in PAD

poor blood flow

lactic acid buildup from anaerobic metabolism

what is claudication

intermittent crampy pain; overwhelming fatigue with exertion

where does claudication pain occur in relation to obstruction

DISTALLY

where is claudiction felt in iliac disease

buttocks and thighs

where is claudication in femoral disease felt

calves

pain at rest is indicative of _

severe occlusive disease

severe occlusive disease may be associated with what skin finding

gangrene

what are the characteristics of wet gangrene

active infection

purulent discharge

cellulitis

pulses on PE

diminished/absent

may be present on doppler

± femoral bruits

skin appearance on PE

shiny, thin, hairless

nail appearance on PE

thickened, discolored

what is dependent rubor

lower leg flushes in dependent position

arterial ulcers usually affect _

heels and toes

which type of ulcer are more painful

arterial

appearance of arterial ulcers

“punched out”

full thickness, pale or necrotic base

venous ulcers are associated with _ (3)

stasis

edema

hyperpigmentation

typical location of venous ulcers

around malleoli

appearance of venous ulcers

diffuse, shallow ulcerations with irregular margins

appearance of the base of venous ulcers

granulation tissue

what causes diabetic foot ulcersr

neuropathy and minor trauma

where are diabetic foot ulcers seen

plantar or lateral surface

assess diabetic foot ulcers for _

infection, cellulitis

abnormal sensory examinatin

are diabetic foot ulcers painful or painless

painless

what is the ankle brachial index

ratio of systolic BP in the ankle : arm

what is a normal ABI

1.0 - 1.4

ABI associated with claudication

0.4-0.9

what does a decreasing ABI suggest

lack of blood flow to the lower extremities

ABI of advanced ischemia

< 0.4

how to record arm BP

bilaterally, take the higher number

indications from patient history for ABI

claudication

non-joint related exertional lower extremity sx’s

impaired walking function

ischemic rest pain

PE findings that indicate taking ABI

abnormal pulse exam

vascular bruit

nonhealing wound

gangrene

4 diagnostic methods for PAD

ultrasonography

MRA

CTA

angiography

arterial duplex US helps to measure what

flow velocities and direction

high velocity blood flow on duplex US suggests _

significant arterial stenoses

downside to MRA imaging

long duration of test, claustrophobia

gold standard of imaging for PAD

angiography

invasive study with injection of contrast media

angiography

what should patients with contrast allergy be treated with

benadryl and prednisone beforehand

medical therapy recs to reduce CV events (5)

statins and PCSK9i’s

smoking cessation

antiplatelet therapy

rivaroxaban

ACEi

3 medical therapy recs to improve walking distance

statins, PCSK9

cilostazol

semaglutide

antiplatelet therapy for PAD

aspirin, clopidogrel or both (DAPT)

what is DAPT

dual anti-platelet therapy, using aspirin and clopidogrel together

percutaneous transluminal angioplasty is better suited for

smaller, focal lesions

what kinds of occlusion lesions is surgery more appropriate for

long segments, multifocal, calcifications

indications for revascularization (5)

intractable claudication

rest pain

ABI < 0.4

ulcers/gangrene

impotence

leriche syndrome

absent femoral pulses

buttock + thigh claudication

impotency

continue _ post-operatively

anti-platelet therapy

when is endartectomy utilized

for discrete lesions

surgical option with greatest patency

aorto-bifemoral bypass

what causes acute limb ischemia

occlusion from an embolus or thrombus

5 P’s of acute limb ischemia

pain

pallor

pulselessness

paresthesia

poikilothermia

paralysis (later on)

what is the rutherford classification used for

acute limb ischemia

4 aspects of the rutherford classification

sensory loss

muscle weakness

arterial doppler

venous doppler

thrombectomy utilizes what device

Fogarty catheter

treatment for acute limb ischemia (4)

thrombolysis

hydration with IV fluids

thrombectomy

revascularization procedures

complications of acute limb ischemia treatment

compartment syndrome

how is compartment syndrome treated

fasciotomy + local wound care

arteries that supply the mesentery

celiac

superior mesenteric

inferior mesenteric

acute mesenteric ischemia is secondary to _

embolus/thrombus

a low flow state

severe abdominal pain out of proportion to PE findings could be a sign of _

acute mesenteric ischemia

chronic mesenteric ischemia clinical presentation

ABD pain after meals

fear of eating → weight loss

epigastric bruit

management of chronic mesenteric ischemia

revascularization

endarterectomy / angioplasty/ stent / bypass

4 causes of acute mesenteric ischemia

embolization

thrombosis

non-occlusive mesenteric ischemia

mesenteric venous thrombosis

demographic of acute mesenteric ischemia

elderly and female

clinical presentation of acute mesenteric ischemia

acute mid-epigastric pain

+/- vomiting

pain out of proportion

diagnosis of acute mesenteric ischemia

ABD X-ray

CBC (would show elevated WBC)

CTA

treatment for acute mesenteric ischemia

IV hydration

gastric depression

thrombolytics/PTA/stent

bowel resection

etiologies of renal artery stenosis

atherosclerosis

fibromuscular dysplasia

4 reasons to suspect renal artery stenosis

acute onset of severe HTN in young patients

acute worsening of BP

resistant HTN

presence of flank bruits

renal artery stenosis treatment

angioplasty or stent

endarterectomy, bypass

nephrectomy if kidney is non functional

diagnsosis of renal artery stenosis

US

CTA/angiography

fibromuscular dysplasia affects what part of the artery

media

hyperplastic fibrosing process that affects the media

fibromuscular dysplasia

fibromuscular dysplasia treatment

anti-platelet therapy

what defines an aortic aneurysm

focal dilation of aortic lumen greater than 2.5x

fusiform aortic aneurysm

symmetrical dilation that involves full circumference

saccular aortic aneurysms

more localized and appear as an outpouching

etiologies of aortic anuerysm

degenerative (most common)

Marfan’s syndrome, loeys dietz (CT diseases)

infection

trauma

most common site for abominal aortic anuerysm

infrarenal abdominal aorta

abdominal aortic aneurysm can lead to what 3 things

rupture/dissection

thromboembolism

compromised renal blood flow

most common compaint of aortic aneurysm

back pain

how does abdominal anuerysm appear on PE

pulsatile, tender abdominal mass

hypotension

acute back pain

best study for screening AAA

ultrasound

use what kind of imaging to follow the size of an established AAA

CTA or CT scan

how often should AAA be measured

q6 months

standard study for pre-op evaluation of collateral vessels with AAA

aortography

criteria to repair AAA

greater than 5cm in size

treatment for AAA

surgical repair with Darcon graft

percutaneous endovascular stent graft

aortic dissection is due to _

a tear in the intima

thoracic dissections are associated with )

hTN and trauma

pain associated with aortic dissection

tearing pain in the chest or abdomen