Term
| lower extremity arterial disease development |
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Definition
• Typically with age, the peripheral arteries build up plaque that narrows the passageways causing them to become stiff.
• PAD results when the peripheral arteries become too narrow or obstructed and limit the blood flow to the legs.
• Individuals with PAD suffer a five-fold increased relative risk of a cardiovascular ischemic event and total mortality that is two to three fold greater than those without PAD |
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Term
| peripheral artery disease definition, most common cause, types, pathophys |
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Definition
• Definition:
- Also known as PAD or PAOD.
- Occlusive disease of the arteries of the lower extremity.
• Most common cause:
- Atherothrombosis
- Others: arteritis, aneurysm + embolism.
• Has both acute and chronic disease
• Pathophysiology:
-Arterial narrowing leads to decreased blood flow = Pain
- Pain results from an imbalance between supply and demand of blood flow |
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Term
| neurogenic vs vascular claudication PAD |
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Definition
neurogenic- distance varies, relief of pain on sitting, no discomfort walking up hill, numbness/achey pain, pulses present, normal skin, occasional weakness, common back pain
Vascular- fixed distance, relief of pain on standing, discomfort walking up hill, pain is tightness, absent pulses, skin- loss of hair, rare weakness, uncommon back pain |
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Term
| etiologies/causes of chronic lower extremity ischemia PAD |
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Definition
• Atherosclerosis
• Thromboangiitis obliterans
• Vasculitis
• Trauma
• Popliteal artery entrapment
• Popliteal cystic adventitial disease |
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Term
| what is collateralization PAD |
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Definition
• Common occurrence
• Existing vessels that increase in size
• Symptomatology becomes less apparent
• Extension of atherosclerosis to collateral bed |
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Term
| what is claudication? 2 locations? PAD |
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Definition
• Cramping sensation
• Calf muscle:
– Femoral artery disease
• Buttocks and thigh: – Aortoiliac disease |
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Term
| management/treatment of claudication PAD |
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Definition
• Modification of risk factors – Improvement in >50%
• Exercises
• Antiplatelet therapies
• Surgical intervention for lifestyle-altering disease – 20-30% eligible
– Risk/benefit ratio
• Patient counseling |
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Term
| critical limb ischemia in PAD |
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Definition
• Tissue loss or ischemic rest pain
– Hair loss, muscle wasting, thin skin, thickened nails
• Approximately 20% require amputation |
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Term
| evaluation/testing in PAD |
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Definition
• Physical examination • Doppler ultrasound
• ABI
• PVR
• Treadmill exercise
• Duplex US
• Angiography
– Regular, CTA, MRA
• Pressure gradient |
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Term
| physical exam of pulses in PAD and ratings |
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Definition
• Pulse intensity should be assessed and should be recorded numerically:
• 0- absent
• 1- diminished
• 2- normal
• 3- bounding
• 4- Cannot be obliterated |
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Term
| findings on vascular physical exam for PAD |
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Definition
• Arterial bruits
• Decreased or absent peripheral pulses • Decreased skin temperature
• Dependent rubor
• Dystrophic nails and shiny, hairless skin • Gangrene
• Ulceration |
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Term
| labs and testing usually done for PAD |
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Definition
• Doppler Ultrasound
• Ankle Brachial Index (ABI)
• Pulse volume recording
• Treadmill (exercise ABI/PVR) • Duplex ultrasound
• Angiography |
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Term
| ankle brachial index results interpretation |
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Definition
>0.9 normal limb, 0.5-0.9 intermittent claudication, <0.4 rest pain, <0.15 gangrene
CAUTION:
Patient’s with Diabetes + Renal Failure:
They have calcified arterial walls which can falsely elevate their ABI |
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Term
| vascular intervention for PAD |
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Definition
• Proper patient selection
• Conservative management • Risk factor modification
• Surgical intervention:
– Lifestyle-altering claudication
– Critical limb ischemia (rest pain or tissue loss) |
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Term
| thromboangitis obliterans/Buerger's Disease is what? |
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Definition
• Chronic inflammatory, thrombotic, nonatherosclerotic, segmental, obliterative, tobacco-associated vasculopathy
• Primarily involving infrapopliteal (below knee) and infrabrachial (below elbow) arteries of young smokers.
• Highly cellular thrombus |
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Term
| presentation of thromboangitis obliterans/Buerger's disease |
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Definition
• Distal extremity ischemia in a smoker before the age of 45-50 years old
• Predominantly men, can occur in women
• Clinical diagnosis
– Smoking history
– Onset before age 50
– Infrapopliteal lesions
– Upper limb involvement
– Absence of other atherosclerotic risk factors |
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Term
| Thromboangitis Obliterans: Angiogram findings |
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Definition
• Involvement of small and medium-sized arteries
• Digital arteries of fingers and toes
– Palmar, plantar, tibial, peroneal, radial, and ulnar arteries
• Segmental occlusive lesions
– Diseased arterial segments interspersed with normal-appearing segments
– More severe disease distally
• Tapering or abrupt arterial occlusions with collateralization around areas of occlusion
– Described as “corkscrew collaterals,” “spider leg,” or “tree root appearance”
• Normal proximal arteries free of atherosclerosis, aneurysms, or other sources of emboli |
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Term
| thromboangitis obliterans/Buerger's disease management/treatment |
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Definition
• Stop smoking
• Anticoagulants, dextran, pentoxyfilline, phenylbutazone, calcium channel blockers, prostaglandin analogues, NSAIDs, etc.
– For pain relief, temporizing of disease but no meaningful success without smoking cessation
• Revascularization can palliate but not durable without smoking cessation |
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Term
| Acute Limb Ischemia 6 P's |
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Definition
• Paresthesias
• Paralysis
• Pain
• Pallor
• Poikilothermia
• Pulselessness |
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Term
| 2 basic causes of acute limb ischemia |
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Definition
• Embolism
- Clot came from somewhere else (e.g. heart) and blocked up the artery
• Thrombosis
- Vessel likely already had some disease and narrowing and because the blood flow slowed down so much it clotted off that part |
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Term
| acute limb ischemia a fib and thrombosis treatment options |
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Definition
• Atrial fibrillation:
– Embolectomy (pull out the thing that plugged it up)
– If no motor/sensory loss à thrombolysis
– If motor/sensory loss à surgical revascularization (bypass)
• Thrombosis:
– If no motor/sensory loss à thrombolysis
– If motor/sensory loss à surgical revascularization (bypass) |
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Term
| Reperfusion Injury and Compartment Syndrome |
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Definition
• Oxygen radicals can cause injury
• Compartment syndrome can occur • Pain with passive motion
• Fasciotomies could be needed |
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Term
| Raynaud’s Disease is what? findings? types? |
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Definition
• Raynaud phenomenon: symptom complexàtriphasic color change of fingers to white (ischemia), blue (cyanosis), red (reperfusion) [patriotic fingers]
• Primary (idiopathic, i.e., no underlying cause) = Raynaud’s disease
• Benign; does not progress to irreversible injury
• Secondary (due to something else, e.g. systemic sclerosis)
– Associated with connective tissue diseases
– Can progress to ulceration, scarring, gangrene in 50% cases |
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Term
| Etiologies/causes of raynaud's disease |
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Definition
• Diseases of the arteries
• Drugs
– Amphetamines, beta-blockers, Clonidine, Ergotamine
• Autoimmune conditions
– SLE, Sjogrens, Scleroderma, RA
• Smoking
• Repeated injury or usage
– Typing, heavy hand tool usage
• Thoracic outlet syndrome
• Increased viscosity – Cryglobulinemia
– Malignancy
• Hypothyroidism
• Carpal tunnel syndrome |
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Term
| management/treatment of reynaud's |
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Definition
• Keep warm (gloves, socks, hat, jacket, thermal underwear)
• Stop smoking
• Medical management
– 1st line = Calcium channel blockers (e.g. nifedipine)
– Others: ARBs, ACEIs, aspirin, anticoagulants, intravenous prostanoids, etc.
– Surgery: periarterial sympathectomy, other revascularization procedures as indicated for occlusive disease (e.g. balloon angioplasty or stenting) |
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