Wake Cv Clinical Evaluation Of The Peripheral Vascular System

Front 1

What is Peripheral Vascular Disease?

Back 1

Disorders of arteries, veins and lymph vessels outside of the heart and brain

Front 2

What are common peripheral artery problems?

Back 2

- Occlusions of carotid arteries and leg arteries
- and aneurysms of the aorta

Front 3

What are some common peripheral vein problems?

Back 3

- Varicose veins
- deep vein thrombosis (DVT)
- lower extremity venous insufficiency and ulcers

Front 4

Scope of peripheral vascular pathology

Back 4

- Arterial occlusive disease
- Aneurysms
- Venous thrombosis and insufficiency

Front 5

Acute Peripheral Artery Occlusion

Back 5

(e.g. embolism or plaque rupture)
- Sudden severe symptoms of end-organ ischemia
- No time to develop compensatory collateral blood flow

Front 6

Chronic Peripheral Artery Occlusion

Back 6

(e.g. atherosclerotic stenosis)
- Slowly progressive symptoms, often less severe
- Time for small bridging collateral arteries to develop, bringing flow around the site of stenosis/occlusion.

Front 7

Common “Chief Complaints” for Vascular System

Back 7

- Leg pain (at rest or with ambulation, claudication)
- Toe ulcers or gangrene
- Leg swelling
- Recent stroke (CVA) or transient ischemic attack (TIA)
- Bruit in the neck
- Pulsatile abdominal mass
- Abdominal aortic aneurysm (AAA) found incidentally on imaging done for another reason

Front 8

Vascular System
Associated risk factors and conditions

Back 8

- Atherosclerosis and its risk factors
- Heart disease, stroke, smoking, diabetes, lipids, etc.
- Altered exercise capacity
- Dyspnea
- Exertional Angina
- Leg pain with ambulation (claudication)
- Clotting disorders or “thrombophillia”
- Family history of vascular problems

Front 9

Hallmarks of Acute Limb Ischemia

Back 9

(The Six P's)
- Pulselessness
- Pain
- Pallor
- Poikilothermia (cold)
- Paresthesias
- Paresis/Paralysis

(Always an emergency)

Front 10

What do you do when you palpate peripheral pulses?

Back 10

- Grading pulse strength
- Vessel caliber (aneurysms)
- Thrill (indicative of stenosis or fistula flow)

Front 11

What do you do when you auscultate peripheral pulses?

Back 11

listen for bruits which are indicative of stenosis

Front 12

What are the effects of severe stenoses?

Back 12

create a pressure drop, turbulence, and loss of energy that can be felt as a vibration (thrill) or ascultated similar to a heart murmur (bruit)

Front 13

What is normal and abnormal in doppler pulses?

Back 13

Normal = Triphasic (systole, diastole, and reverse flow heard)

Abnormal= Biphasic or Monophasic (blunted, lacking flow reversal)

Front 14

Grading of Pulses
What is absent?

Back 14

0/2

Front 15

Grading of Pulses
What is blunted or diminished?

Back 15

1+/2

Front 16

Grading of Pulses
What is normal?

Back 16

2+/2

Front 17

Skin changes associated with arterial pathology

Back 17

- Decreased temp
- Pallor, mottling (with cap. refill)
- Hair loss (above/around ankle = common with ischemia)
- Ulceration
- Gangrene

(often seen in the digits of hands and feet)

Front 18

Skin changes associated with venous pathology

Back 18

- Edema
- Varicosities (more visible with standing)
- Dermatitis (lipodermatosclerosis)
- Thickened skin
- Bronze discoloration
- Ulceration
- Gaiter distribution

Front 19

Diagnostic studies used with PVD

Back 19

- Ankle brachial index (ABI)
- Duplex ultrasonography
- CT angiography (CTA)
- Magnetic resonance angiography (MRA)
- Digital subtraction angiography (DSA)

Front 20

Ankle-Brachial Index (ABI)

Back 20

-Opening pressures (doppler signal when the brachial or ankle artery begins to open) measured by Doppler, supine, at rest.
-Highest of DP or PT in each leg divided by highest brachial artery pressure (so you are using one arm and two legs in your calculations).

Front 21

Ankle-Brachial Index (ABI)
What does a value of >1.0 mean?

Back 21

Normal or possibly non-compressible from heavy calcification (e.g. diabetes)

It is normal for legs to have a higher opening pressure.

Front 22

Ankle-Brachial Index (ABI)
What does a value of <0.9 mean?

Back 22

Abnormal, likely claudication (mean 0.6), marker of increased risk for heart disease

Front 23

Ankle-Brachial Index (ABI)
What does a value of <0.6 mean?

Back 23

Rest pain (mean 0.3)

Front 24

Ankle-Brachial Index (ABI)
What does a value of <0.3 mean?

Back 24

Non-healing ulcers or gangrene (mean 0.1)

Front 25

When is Duplex Ultrasonography used?

Back 25

- Gold standard in screening for carotid occlusive disease
- Also used in renal, mesenteric and extremity arteries and bypass grafts to define stenoses.
- Gold standard in screening for Deep Venous Thrombosis
- Noncompressible enlarged vein , abnormal flow, visible thrombus

Front 26

What is Duplex Ultrasonography?

Back 26

-Combines B-mode ultrasound & color Doppler with spectral analysis
-Increased velocities and spectral broadening correlate with degree of stenosis
(red = rapid flow in forward direction; blue = rapid flow in reverse direction)
- Picture allows you to examine for plaques and gross sxral changes
- Cheap and non-invassive

Front 27

Pulse-Volume Recordings and Segmental Pressures

Back 27

- Used in extremities proximal to distal… to measure the wave form that you can use to monitor flow down the leg

Normal: waveform amplitude remains the same with brisk upstroke and no blunting

Front 28

Digital Subtraction Angiography (DSA)
Potential for Treatment

Back 28

- Angioplasty
- Stent

Front 29

Digital Subtraction Angiography (DSA)
Contraindication

Back 29

- Iodinated contrast (is nephrotoxic) may cause renal insufficiency
- Allergy to contrast (anaphylaxis)
- Drug reactions (i.e. Metformin)

Front 30

Digital Subtraction Angiography (DSA)
Gold Standard for?

Back 30

- Artery occlusive disease
- Detailed lumen structure (determine the location and degree of blockage)

Front 31

Are there risks with Digital Subtraction Angiography (DSA)?

Back 31

Yes. It is INVASIVE.
- requires artery puncture
- risk of bleeding (may require transfusions)
- radiation exposure

Front 32

CT Angiography (CTA)
Contraindications

Back 32

Iodinated contrast
- renal insufficiency
- allergic reactions
- drug reactions (i.e. Metformin)

Front 33

CT Angiography (CTA)

Back 33

- Non-Invasive (radiation)
- Images (given you lots of information about all aspects of artery)
- Artery wall
- Calcium
- Thrombus
- Lumen
- Adjacent structures
- 2D and 3D reformatting
- Indicated for aneursyms and dissections

Front 34

MR Angiography (ceMRA)

Back 34

- Non Invasive
Images
- Lower resolution than CTA
- Artery wall
- Lumen
- Adjacent structures
- 2D and 3D reformatting

Front 35

MR Angiography (ceMRA)
Contraindication

Back 35

- Gadolinium contrast
- renal insufficiency
- Dermatofibrosis
Metal
- Pacemakers
- Recent stents
Claustophobia

Front 36

Which resolution is better CTA or ceMRA?

Back 36

CTA