Difference between revisions of "Peripheral artery disease"

(Clinical Features)
 
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== Background ==
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''See [[acute arterial ischemia]] for acute limb ischemia''
*Peripheral artery disease = ABI <0.9
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==Background==
*>80% of pts are either former or current smokers
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*Peripheral artery disease = ABI <0.9 (normal ≥1.0)<ref>Heald CL, et al. Ankle Brachial Index C. Risk of mortality and cardiovascular disease associated with the ankle-brachial index: systematic review. Atherosclerosis. 2006;189:61–69.</ref>
 +
*>70% of patients are either former or current smokers<ref>Ng EL, et al. Prevalence of and risk factors for peripheral arterial disease in older adults in an Australian emergency department. Vascular. 2014; 22(1):1-12.</ref>
 
*33% of deaths are from reperfusion injury
 
*33% of deaths are from reperfusion injury
**Myoglobinemia, ARF, incr CK
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**Myoglobinemia, ARF, increased CK
 
*Thrombosis accounts for >80% of lower limb ischemia
 
*Thrombosis accounts for >80% of lower limb ischemia
 +
*PAD indicates systemic atherosclerosis<ref>Levy PJ. Epidemiology and pathophysiology of peripheral arterial disease. Clin Cornerstone. 2002;4:1–15.</ref>
  
== Diagnosis ==
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==Clinical Features==
History
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[[File:NecrosisDuetoPAD.jpg|thumb|Peripheral arterial disease resulting in necrosis of multiple toes]]
*6 P's: Pain, pallor, paralysis, pulselessness, paresthesias, polar
 
**Paresthesia and weakness are early findings
 
**Preservation of light touch is good guide to tissue viability
 
**Anesthesia and paralysis = impending gangrene
 
**Absence of pulse in pt w/ chronic disease only helpful if accompanied by skin changes
 
**Pain with leg elevation
 
*Leg claudication
 
Physical Exam
 
 
*Shiny, hyperpigmented skin, hair loss
 
*Shiny, hyperpigmented skin, hair loss
 
*Ulceration
 
*Ulceration
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*Cap refill >3sec
 
*Cap refill >3sec
  
== Work-Up ==
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==Differential Diagnosis==
*ABI
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*[[Phlegmasia Alba Dolens]]
**Ratio of sBP of post tibial or DP to highest brachial pressure in either arm
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*[[Phlegmasia Cerulea Colens]]
**<0.40 = potentially limb-threatening vascular disease
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*[[Ankle fracture]]
**0.41-0.90 = claudication
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*[[Venous thromboembolism]]
**>1.3 = noncompressible vessel (severe vascular calcification)
 
*Imaging
 
**Ultrasound
 
***Accurate for detecting obstruction in femoral/popliteal/bypass grafts
 
****Sn declines at/below the calf
 
**CTA
 
***Sensitivity similar to that of conventional angiography
 
  
== DDx ==
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{{Foot diagnoses}}
*Phlegmasia cerulea dolens (severe DVT)
 
*Phlegmasia alba dolens (severe DVT + arterial spasm)
 
**Seen in pregnant women
 
**Arterial spasm is transient (do not confuse w/ arterial occlusion)
 
  
==Treatment==
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==Evaluation==
Acute Limb Ischemia
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===ABI===
*Unfractionated Heparin
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*Measuring
**80 units/kg bolus; then infuse 18units/kg/hr
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*#Position patient supine
*ASA
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*#Measure SBP from both brachial arteries using cuff and handheld Doppler over the AC fossa
*Dependent positioning
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*#Measure SBP from both DP and PT arteries using cuff placed just proximal to the malleoli with Doppler over artery (5-8% of normal patients have absent DP pulse)
*Pain control
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*#Calculate ABI on each leg by taking the highest ankle SBP divided by the highest brachial SBP and record to 2 decimal places
*Fluid resus / tx of HF as needed to improve limb perfusion
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*Using calculation
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**0.91–1.30: normal
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**0.70–0.90: mild occlusion
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**0.40–0.69: moderate occlusion
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**<0.40: severe occlusion
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**>1.30: poorly compressible/calcified vessels
 +
===Imaging===
 +
*Xray
 +
**Little use or benefit
 +
*Ultrasound
 +
**Accurate for detecting obstruction in femoral/popliteal/bypass grafts
 +
***Sn declines at/below the calf
 +
**Quality of signal (triphasic, biphasic, monophasic) is important to note
 +
*CTA
 +
**Sensitivity similar to that of conventional angiography
 +
*MRI
 +
**Limited utility in the ED setting
 +
**Detailed images of vasculature can be taken and plaques identified
  
== Source ==
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==Management==
Tintinalli
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*Chronic PAD can recieve outpatient management (by vascular)
  
 +
==Disposition==
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*Chronic PAD can be managed as an outpatient
 +
 +
==See Also==
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*[[Foot Diagnoses]]
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*[[Vascular injury]]
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==External Links==
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*[http://stanfordmedicine25.stanford.edu/the25/ankle.html Stanford Medicine 25: Measuring ABI]
 +
 +
==References==
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<references/>
 +
 +
[[Category:Vascular]]
 
[[Category:Trauma]]
 
[[Category:Trauma]]
[[Category:Surg]]
+
[[Category:Surgery]]

Latest revision as of 07:05, 6 March 2019

See acute arterial ischemia for acute limb ischemia

Background

  • Peripheral artery disease = ABI <0.9 (normal ≥1.0)[1]
  • >70% of patients are either former or current smokers[2]
  • 33% of deaths are from reperfusion injury
    • Myoglobinemia, ARF, increased CK
  • Thrombosis accounts for >80% of lower limb ischemia
  • PAD indicates systemic atherosclerosis[3]

Clinical Features

Peripheral arterial disease resulting in necrosis of multiple toes
  • Shiny, hyperpigmented skin, hair loss
  • Ulceration
    • Tend to be on foot/toes, more painful than venous ulcers
  • Cap refill >3sec

Differential Diagnosis

Foot diagnoses

Acute

Subacute/Chronic

Evaluation

ABI

  • Measuring
    1. Position patient supine
    2. Measure SBP from both brachial arteries using cuff and handheld Doppler over the AC fossa
    3. Measure SBP from both DP and PT arteries using cuff placed just proximal to the malleoli with Doppler over artery (5-8% of normal patients have absent DP pulse)
    4. Calculate ABI on each leg by taking the highest ankle SBP divided by the highest brachial SBP and record to 2 decimal places
  • Using calculation
    • 0.91–1.30: normal
    • 0.70–0.90: mild occlusion
    • 0.40–0.69: moderate occlusion
    • <0.40: severe occlusion
    • >1.30: poorly compressible/calcified vessels

Imaging

  • Xray
    • Little use or benefit
  • Ultrasound
    • Accurate for detecting obstruction in femoral/popliteal/bypass grafts
      • Sn declines at/below the calf
    • Quality of signal (triphasic, biphasic, monophasic) is important to note
  • CTA
    • Sensitivity similar to that of conventional angiography
  • MRI
    • Limited utility in the ED setting
    • Detailed images of vasculature can be taken and plaques identified

Management

  • Chronic PAD can recieve outpatient management (by vascular)

Disposition

  • Chronic PAD can be managed as an outpatient

See Also

External Links

References

  1. Heald CL, et al. Ankle Brachial Index C. Risk of mortality and cardiovascular disease associated with the ankle-brachial index: systematic review. Atherosclerosis. 2006;189:61–69.
  2. Ng EL, et al. Prevalence of and risk factors for peripheral arterial disease in older adults in an Australian emergency department. Vascular. 2014; 22(1):1-12.
  3. Levy PJ. Epidemiology and pathophysiology of peripheral arterial disease. Clin Cornerstone. 2002;4:1–15.