Wake Cv Pad

Front 1

What is the most common site of PAD?

Back 1

- The percentage of arterial surface with atherosclerotic lesions was the greatest in distal abdominal aorta (AA)
- Total lesion area for the AA was greater in women than in men

Front 2

What are the effects of smoking on PAD?

Back 2

Smoking selectively affects atherosclerotic changes in Abdominal Aorta at a younger age than in the coronary arteries
(this is in 2800 subjects ages 15-34 yrs)

Front 3

When patients have chronic Leg Ischemia Symptoms, what do they say?

Back 3

- “My legs are getting tired”
- “I have a Charlie horse”
- “My legs are achy and crampy when I walk, probably I’m out of shape, or I’m just getting older”
- “My feet get numb when I cross my legs”
- “I am afraid to drive longer distances”
- “I get more pain especially when I’m climbing stairs”
- “I was told to be too young to have circulation problems”

Front 4

Types of Claudication

Back 4

- Intermittent (arterial) claudication

- Spinal (neurological, or pseudo) claudication

- Venous claudication (postphlebitic syndrome; chronic venous insufficiency)

- “Arthritic” claudication (“good days – bad days”)

Front 5

Intermittent Claudication

Back 5

- Exertional aching pain, cramping, tightness, fatigue
- Occurs in MUSCLE GROUPS, not in joints
- The location of claudication symptoms depends on the anatomic level of PAD (i.e. aorto-iliac, infra-inguinal, infra-popliteal)
- Reproducible from one day to the next, and initially may become more noticeable while walking on incline
- Resolves completely with the rest
- Occurs again after the same walking distance once activity has been resumed

A FXNAL LIMITATION OF PAD

Front 6

When does PAD show symptoms?

Back 6

When PAD causes stenosis that is >= 75% of the vessel diameter
.: symptoms develop at sever gross anatomical sxral changes

Front 7

Lifestyle Consequences of Intermittent Claudication

Back 7

- Social, personal, occupational activities may be limited by ischemic pain
- Maximal walking speed is 1-2 mph vs 3-4 mph in healthy population
- Functional ability is similar to NYHA Class III CHF
- Maximal walking distance is limited

Front 8

Differential Diagnosis in Patients with A History Suggestive of Intermittent Claudication

Back 8

Atherosclerosis
Thrombangiitis obliterans (Buerger’s Disease)
Popliteal artery entrapment syndrome
Fibromuscular dysplasia
Cystic adventitial disease of popliteal artery
Cocaine-abuse
Ergotamine use/abuse
Peripheral neuropathy
Lumbar canal stenosis
Degenerative disease of hip and lumbar spine

Front 9

Atheromatous Embolization

Back 9

- Precipitating (associated) factors: arteriography; surgery; aneurysms
- Biopsy – most effective for diagnosis (cholesterol crystals)
- Skin changes:
- purple, or “blue toes”
- gangrenous digits; livedo reticularis
- Look for the source of embolization and intervene in order to prevent further events

Front 10

“5 P’s” of Acute Limb Ischemia

Back 10

Pulseless
Pain
Pallor
Paralysis
Paresthesiae

Front 11

Independent Risk Factors for PAD

Back 11

3 most common:
- DM
- Current Smoking
- Age (5-year increments)

- HTN
- Homocysteine
- Total Cholesterol

Front 12

Dyslipidemia in PAD Patients
(in descending order)

Back 12

High triglycerides
Low HDL-cholesterol
Small-LDL particles
High LDL-cholesterol
High lipoprotein (a)

- the first 2 are the most common

Front 13

Physical Examination in PAD

Back 13

- Impaired leg pulses
- Bruits (abdominal, femoral)
- Skin color changes; rubor on dependency
- Skin temperature changes
- Trophic skin changes; deformities of slowly growing nails with onychogryphosis
- Pallor/pain/tingling on elevation of ischemic leg

Front 14

Non-Invasive Evaluation of Lower Extremity Circulation in PAD

Back 14

- Resting ankle-brachial index (ABI)
- Resting segmental pressures at different levels
- Resting pulse-volume recordings (PVR)
- Exercise testing – to establish presence of hemodynamically-significant arterial disease
- Especially useful in patients with claudication and normal ABIs at rest
- Duplex (color-assisted) ultrasound – can detect stenosis and measure flow in large arteries (i.e. iliac, femoral)
- Transcutaneous oximetry

Front 15

How specific and sensitive is an ABI for PAD

Back 15

- The ABI is 95% sensitive and 99% specific for PAD
- Validated against arteriogram
- Performed with handheld Doppler

Front 16

Claudication occurs under an ankle-brachial index of?

Back 16

ABI <0.6

Front 17

Where do occlusions occur in PAD?

Back 17

at bifrucations

Front 18

How do you distinguish between SFA and PF on imaging?

Back 18

- The Profunda femoris is always lateral to SFA
- SFA has very few, if any, branches

Front 19

In imaging how do you distinguish between the anterior tibial, posterior tibial and peroneal arteries?

Back 19

Anterior Tibial – most lateral
Posterior Tibial
Peroneal – in the center

Front 20

Collateral Circulation in PAD

Back 20

- Develops to maintain distal circulation
- Presence of well-developed collateral circulation on the arteriogram indicates chronic ischemic process
- Patients with severe segmental occlusive disease may have “normal” peripheral pulses and resting ABI
- Exercise --> increase metabolic demand to the muscles --> increase blood shunting via collaterals --> distal vasodilation --> decrease pressure

Front 21

What are the major collateral pathways in the lower extremities?

Back 21

a) Lumbar aortic branches (Aortic disease)
b) Internal iliac system and pelvic circulation (CIA disease)
c) Circumflex femoral arteries (CFA disease)
d) Profunda femoris (SFA disease)
e) Geniculate arteries (PA disease)

Front 22

Arteriography - Complications

Back 22

- Arterial injury:
- pseudoaneurysm
- arterio-venous fistula
- thrombosis
- Atheromatous embolization (legs, kidneys, bowel)
- Contrast nephropathy
- Morbidity

Front 23

Leriche’s Syndrome

Back 23

Focal occlusion dz in distal AA and proximal iliac arteries

Front 24

Who was in CAPRIE?
CAPRIE – Clopidogrel vs Aspirin in Patients at Risk of Ischemic Events

Back 24

Study looked at patients who had one of the following: a recent ischemic stroke (<6 months), recent MI (<35 days) or established PAD.

Front 25

What did the CAPRIE study show?

Back 25

It is a prospective, randomized, blinded, multicentral, multinational.
- Patients were treated with clopidogrel (75 mg) or Aspirin (325 mg) for 3 years.
- Patients treated with Clopidogrel had better mortality and fewer cardiovascular events... SPECIFICALLY FOR THE PATIENTS WITH PAD

Front 26

Medical Interventions To Improve Claudication Symptoms

Back 26

- Exercise therapy (limited availability of supervised therapy)
- Smoking cessation
- Cilostazol (contraindicated in patients with heart failure)
- Pentoxifyline (rarely used; near placebo effect)
- Propionyl-L-carnitine
- Combination therapy:
medications + exercise + smoking cessation

* Combination therapy is KEY

Front 27

Contraindications of Cilostazol

Back 27

Contraindicated in heart disease because cardiac death can result form phosphodiesterase III

Front 28

Inhibition of phosphodiesterase III ( c-AMP)

Back 28

- inhibition of platelet aggregation
- inhibition of thrombosis
- vasodilation (only occurs in the collateral healthy vessels)
- inhibition of smooth muscle proliferation (in vitro)
- ABI

Front 29

Action of Cilostazol

Back 29

- inhibition of phosphodiesterase III (increase cAMP)

- improves quality of life for PAD patients
- significant increase in walking distance and walking speed over pentoxifeyline and placebo

Front 30

Why do patients with PAD need combination medicines (clopidogrel and cilostazol)?

Back 30

because clopidogrel prevents ischemic CV events and Cilostazol improve claudication symptoms

Front 31

Indications for Revascularization in PAD

Back 31

- Claudication: Lifestyle limiting with vocational implications; younger adults
- Critical leg ischemia: rest pain; non-healing ischemic ulcerations; gangrene

Front 32

What are the methods for revascularization in PAD?

Back 32

Endovascular (Arterial dilation ± stent placement; atherectomy)

Surgical (Endarterectomy; Arterial bypass)

Front 33

How do you identify patients as risk for PAD?

Back 33

- Any patient with exertional leg pain
- Patients >= 50 years of age with risk factors (smokers, diabetes)
- Patients >= 40 years of age with risk factors and strong family history of cardiovascular disease
- All patients >= 70 years of age