Peripheral artery disease: Difference between revisions
m (Rossdonaldson1 moved page Peripheral Artery Disease to Peripheral artery disease) |
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*[[Venous thromboembolism]] | *[[Venous thromboembolism]] | ||
== | ==Diagnosis== | ||
===ABI=== | |||
*Measuring | *Measuring | ||
*#Position patient supine | *#Position patient supine | ||
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**<0.40: severe occlusion | **<0.40: severe occlusion | ||
**>1.30: poorly compressible/calcified vessels | **>1.30: poorly compressible/calcified vessels | ||
===Imaging=== | |||
*Xray | *Xray | ||
**Little use or benefit | **Little use or benefit | ||
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**Detailed images of vasculature can be taken and plaques identified | **Detailed images of vasculature can be taken and plaques identified | ||
== | ==Management== | ||
Acute Limb Ischemia | Acute Limb Ischemia | ||
*[[Unfractionated Heparin]] | *[[Unfractionated Heparin]] | ||
**80 units/kg bolus; then infuse 18units/kg/hr | **80 units/kg bolus; then infuse 18units/kg/hr | ||
*ASA | *[[ASA]] | ||
*Dependent positioning | *Dependent positioning | ||
*Pain control | *Pain control | ||
Revision as of 16:45, 8 June 2015
Background
- Peripheral artery disease = ABI <0.9 (normal ≥1.0)[1]
- >70% of pts are either former or current smokers[2]
- 33% of deaths are from reperfusion injury
- Myoglobinemia, ARF, incr CK
- Thrombosis accounts for >80% of lower limb ischemia
- PAD indicates systemic atherosclerosis[3]
Clinical Features
6 P's
- Paraesthesia - With weakness are early findings and preservation of light touch is good guide to viability
- Paralysis - impending gangrene
- Pain - claudication or pain with leg elevation
- Pallor
- Pulselessness - helpful only if accompanies by skin changes
- Poikilothermia
Physical Exam
- Shiny, hyperpigmented skin, hair loss
- Ulceration
- Tend to be on foot/toes, more painful than venous ulcers
- Cap refill >3sec
Differential Diagnosis
Diagnosis
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
- Accurate for detecting obstruction in femoral/popliteal/bypass grafts
- 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
Acute Limb Ischemia
- Unfractionated Heparin
- 80 units/kg bolus; then infuse 18units/kg/hr
- ASA
- Dependent positioning
- Pain control
- Fluid resuscitation and treatment of heart failure as needed to improve limb perfusion
- Vascular surgery consultation (clot retrieval, balloon angioplasty, intraarterial tPA, stenting, bypass)
Disposition
- Acute limb ischemia requires inpatient management
- Chronic PAD can be managed as an outpatient
See Also
External Links
References
- ↑ 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.
- ↑ 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.
- ↑ Levy PJ. Epidemiology and pathophysiology of peripheral arterial disease. Clin Cornerstone. 2002;4:1–15.