Difference between revisions of "Peripheral artery disease"

(Clinical Features)
 
(31 intermediate revisions by 5 users not shown)
Line 1: Line 1:
 +
''See [[acute arterial ischemia]] for acute limb ischemia''
 
==Background==
 
==Background==
*Peripheral artery disease = ABI <0.9
+
*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>
*>80% of pts are either former or current smokers
+
*>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
+
**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==
+
==Clinical Features==
History
+
[[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
 
Physical Exam
 
 
*Shiny, hyperpigmented skin, hair loss
 
*Shiny, hyperpigmented skin, hair loss
 
*Ulceration
 
*Ulceration
Line 20: Line 15:
 
*Cap refill >3sec
 
*Cap refill >3sec
  
==Work-Up==
+
==Differential Diagnosis==
*ABI
+
*[[Phlegmasia Alba Dolens]]
**Ratio of sBP of post tibial or DP to highest brachial pressure in either arm
+
*[[Phlegmasia Cerulea Colens]]
**<0.40 = potentially limb-threatening vascular disease
+
*[[Ankle fracture]]
**0.41-0.90 = claudication
+
*[[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
 
**CT (with contrast)
 
***Sensitivity similar to that of aortography
 
  
==DDx==
+
{{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==
+
==Evaluation==
 +
===ABI===
 +
*Measuring
 +
*#Position patient supine
 +
*#Measure SBP from both brachial arteries using cuff and handheld Doppler over the AC fossa
 +
*#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)
 +
*#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==
 
==Disposition==
 +
*Chronic PAD can be managed as an outpatient
  
{| cellspacing="0" cellpadding="0" border="0" bgcolor="#ffffff"
+
==See Also==
|-
+
*[[Foot Diagnoses]]
| bgcolor="#CCCCCC" style="color: rgb(51, 51, 51); border-right-color: rgb(102, 102, 102); border-right-width: 1px; border-right-style: solid; border-top-color: rgb(102, 102, 102); border-top-width: 1px; border-top-style: solid; border-left-color: rgb(102, 102, 102); border-left-width: 1px; border-left-style: solid; " |
+
*[[Vascular injury]]
{| border="0" cellpadding="3" cellspacing="0" width="100%"
 
|-
 
| style="color: rgb(51, 51, 51); " |
 
Table 64-5 ED Therapy for Acute Limb Ischemia
 
<br/>
 
|}
 
  
|-
+
==External Links==
| style="color: rgb(51, 51, 51); " |
+
*[http://stanfordmedicine25.stanford.edu/the25/ankle.html Stanford Medicine 25: Measuring ABI]
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" width="100%"
 
|}
 
  
|}
+
==References==
 
+
<references/>
 
 
Although no studies to date have established an unequivocally beneficial role of any generally administered antithrombotic agent for acute arterial occlusion, when the diagnosis of acute limb ischemia is known or suspected, the current practice is the immediate administration of IV unfractionated heparin. Weight-adjusted dosing of unfractionated heparin at an 80 units/kg bolus followed by an infusion of 18 units/kg/h rapidly achieves a therapeutic heparin level and activated partial thromboplastin time.
 
 
 
Supportive therapies, including the administration of analgesia and dependent positioning of the extremity, should not be overlooked. Fluid resuscitation and treatment of heart failure and dysrhythmias are sometimes necessary to improve limb perfusion.
 
 
 
Catheter-directed intra-arterial thrombolysis has replaced systemic thrombolysis for peripheral artery embolic or thrombotic disease.
 
 
 
The final recommendation is that catheter-directed thrombolysis should be considered a treatment option in patients with thrombotic or embolic disease of <14 days provided the patient is at low risk for myonecrosis or ischemic nerve damage during the time required to achieve reperfusion.1
 
 
 
 
 
The decision regarding the method of revascularization is a complex one.
 
 
 
PTA may be a better option for patients with multiple comorbidities who are at higher risk when undergoing major surgery and for those with a short life expectancy. In general, open surgery seems to be a more attractive option for patients with inflow disease and multifocal and long-segment disease. Open surgery still is the gold standard therapy and an important treatment option for patients with a favorable long-term prognosis.
 
 
 
The American College of Cardiology/American Heart Association 2005 guidelines included cilostazol, a phosphodiesterase inhibitor, as a Class I recommendation for the treatment of claudication in patients with obstructive arterial disease2 (avoid in patients with heart failure). Pentoxifylline is considered a second-line therapy for the treatment of claudication (Class IIb)
 
 
 
 
 
 
 
 
 
==Source==
 
Tintinalli
 
  
 +
[[Category:Vascular]]
 
[[Category:Trauma]]
 
[[Category:Trauma]]
 +
[[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.