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clinical atherosclerosis - PAD
CVM
34
Medical
Graduate
03/24/2010

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Term
what is PAD?
Definition
peripheral arterial disease, a concept of developing progressive atherosclerosis in the distal arterial system which feeds the lower extremities
Term
what what percent occulsion of arteries do you start seeing flow limitation distally? can this progress to total occulsion at a segmental level?
Definition
75%, it is possible to have total occulsion of a vessel at a segmental level
Term
what is intermittent claudication? where does it often occur? can it progress?
Definition
ischemically derived cramping pain in the legs during often experienced during walking, which often occurs in the calves. it can progress to where the occlusion becomes tighters and/or multi-segmental
Term
what does the distal abdominal aorta bifurcate into?
Definition
the common illiac -> external and internal illiac. the internal feeds the genitals and buttocks, and the external becomes the femoral which goes down to the knee (superficial femoral artery: site of caths) where it trifurcates in the popliteal fossa giving off the ant tibial -> the dorsalis pedis (dorsum), the post tibial -> goes down the medial malleolar gutter, and the peroneal which goes into the lateral malleolar gutter
Term
**where is the most common area of occulusion in non-diabetic pts' lower extremity?
Definition
the superficial femoral artery
Term
**where is the most common area of atherosclerotic narrowing in a diabetic pts?
Definition
the popliteal artery in the popliteal fossa (diabetics favor smaller vessel disease)
Term
in diabetics and non-diabetics where is claudication if either the sup femoral artery or popliteal artery are occuluded?
Definition
in the calves
Term
in diabetics whose occulusion happens in the anterior and posterior tibial arteries (even smaller), where does their claudication occur?
Definition
in the foot and arch muscles
Term
what happens if proximal occulusion in the internal illiac?
Definition
claudication can develop in the ipsilateral buttock and upper thigh. males can also get mild ED - *leriche’s syndrome*
Term
what is proximal occulusion in the internal illiac commonly misdiagnosed as?
Definition
DJV of hip, L1, L2 spinal root neuropathy
Term
how is occlusion of the internal illiac treated?
Definition
angiogram, balloon and stint or bypass
Term
what is an ABI?
Definition
ankle brachial index, which is a ratio of ankle systolic pressure/brachial systolic pressure that quantitates arterial insufficiency of lower extremities using a doppler and BP cuff
Term
what should an ABI be?
Definition
greater than 1, b/c radii of ankle arteries are smaller than radii of brachial artery, and thus should have higher pressure
Term
what happens to leg pressure as progressive atherosclerotic flow-limiting lesions develop (often in SFA, popliteal arteries or in series)?
Definition
pressures in ankle arteries drop, and ABI drops below normal
Term
what ABI is diagnostic for PAD? is this symptomatic in terms of pain? are pts at a higher risk w/this? do pts with this likely have occusions?
Definition
<.9, at which pts may not experience any other symptoms, such as pain - but cardiac mortality at this point is 6-8x more than other people in your same demographic. pts with .9 and lower ABI have a 95% chance of having a 50% cross sectional occulsion somewhere in their leg
Term
is a 50% arterial occlusion flow limiting?
Definition
no, 70-75% is
Term
if someone has a .9 or less ABI, this puts them at a high risk for cardiac disease. what does this mean in terms of how other risk factors need to be regulated?
Definition
their cholesterol needs to be <190, LDL needs to be <70 (w/aggressive diet and medical therapy, plaque may be reabsorbed)
Term
why does smoking need to be stopped if a pt has an ABI <.9?
Definition
smoking increases systemic vascular resistance in collateral flow, and in areas such as the geniculate around the knee, this can be a major problem
Term
what other risk factors besides smoking need to be addressed in pts with an ABI <.9?
Definition
cholesterol, HTN (<130/80 if diabetic, <140/90 if non-diabetic), fat, and sugar if diabetic
Term
what is the common treatment for PAD?
Definition
stop smoking, exercise daily, modify cholesterol, control diabetes, lower blood pressure, and lose weight
Term
what are the medications commonly prescribed for PAD?
Definition
methylxanthine inhibitors, trental, pletal, and an anti-platelet cocktail
Term
what do methylxanthine inhibitors do?
Definition
this is a phosphodiesterase inhibitor that elevates cAMP in cells (vascular and endothelia), which leads to a vasodilatory state - anti-thrombotic conditions (opens up collaterals)
Term
what is a warning for pletal? can it help with walkability?
Definition
pts cant take this if they have ever had CHF (excludes a lot of geriatric pts - they should take trental). taken 3x/day, pletal can improve walkability
Term
what is the antiplatelet cocktail commonly prescribed for PAD?
Definition
asa and plavix daily, which inhibit platelets at different sites - reduces cardiac mortality by 30-50%, and increases walkability with trental/pletal
Term
what is characteristic of pts with .9-.8 ABI? (mild PAD)
Definition
they are generally asymptomatic, though the distal arteries in the foot may be mildly dampended in intensity
Term
what is characteristic of pts with .79-.65 ABI? (moderate PAD)
Definition
symptoms start, and pts claudicates at about 2 city blocks (1000 ft)
Term
what is characteristic of pts with .64-.5 ABI? (severe PAD)
Definition
these pts can claudicate at a city block or half
Term
what is characteristic of pts with <.5 ABI?
Definition
this is considered resting ischemia, and between .4-.25, pts are home-bound, at less than .25, pts can develop rubor pallor syndrome
Term
what is rubor pallor syndrome?
Definition
when ABI is <.25, gravity is the only thing pulling RBCs to the foot.  if gravity is taken away (feet are raised), the foot goes white and is very painful, when they stand up it turns bright red w/the return of blood.  pt w/this are one step away from amputation b/c resultant gangrene, cellulitis, and osteomyelitis are unresponsive to antibx that cannot reach the area due to ischemia
Term
why is claudication not often mentioned in checkups?
Definition
b/c it is considered "part of getting older" and it comes on very slowly
Term
what is a quick screen for arterial health?
Definition
a handheld doppler on any artery should give a triphasic sound, but w/ABI's <.8, you may have mono or biphasic sound characteristic of flow-limiting proximal PAD (ischemia is most potent vasodilator known)
Term
how is an ABI performed?
Definition
in both arms, find the artery, pump up a blood pressure cuff until silent, slowly let it out - and when you hear the first sound through the doppler, its the systolic pressure. do the same thing in the dorsalis pedis (if hear one or two sounds you already know you have <0.80), and listen for the first sound (systolic) - then do the same for the post tibial and peroneal in each foot.
Term
how is the ABI calculated?
Definition
take the highest ankle systolic and divide it by the highest arm systolic
Term
how does the ABI characterize PAD?
Definition
it quantitates it
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