Peripheral Artery Disease Research Paper Outline

Peripheral Vascular Disease

I. Definition of the disease
A. Peripheral Arterial Disease
1. Atherosclerotic:
a. Atheroma consisting of a core of cholesterol joined to proteins with a fibrous intravascular covering
i. Gradual progression ii. Segmental progression
2. Nonatherosclerotic:
a. Inflammatory and thrombotic process of arteries unrelated to atherosclerosis
i. Faster progression than atherosclerotic disease
II. Etiology/pathogenesis
A. Atherosclerotic
1. Risk factors
a. Age
b. Sex
c. Gender
i. Male
d. Environmental factors
i. Tobacco use

ii. Obesity
e. Underlying disease
i. Diabetes Mellitus ii. Hypertension iii. Dyslipidemia iv. Hyperhomocysteinemia
v. Coronary Artery Disease
f. Genetic Predisposition
B. Nonatheroscerlotic
1. Risk Factors
a. Vascular injury
i. Surgery ii. Trauma
b. Phlebitis
c. Autoimmune disease
i. Vasculitides ii. Arthritis iii. Coagulopathy
d. Radiation-induced
e. Tobacco Use
i. Thromboangitis Obliterans
III. Pertinent historical findings/clinical symptoms
A. Occurrence
1. Asymptomatic
a. No symptoms
i. ½ of all cases
2. Symptomatic
a. Intermittent claudication
b. Weakness in legs
c. Numbness in legs
d. Rest leg pain
e. Skin ulceration
f. Gangrene
g. Impotence
B. Prevalence
1. US prevalence: 4%
2. Age-adjusted prevalence: close to 12%.
3. Primary care prevalence: up to 29%
IV. Pertinent Physical Exam Findings
A. Peripheral Vascular Exam
1. Reduced or absent pulses
2. Bruits
3. Dependent rubor
4. Cyanosis
5. Cool extremities
6. Hypertrophic nails
7. Skin atrophy
8. Hair loss
B. Cardiac Exam
1. Murmurs
2. Irregular Heart Rate
V. Differential diagnosis
A. Arterial Embolism
B. Deep vein thrombosis
C. Thromboangitis obiterans
D. Osteoarthritis
E. Restless leg syndrome
F. Peripheral neuropathy
G. Spinal stenosis
H. Intervertebral disc prolapse
VI. Diagnostic evaluations
A. Procedures
1. Doppler ankle-brachial index
a. Obtained if history and physical exam suggests PAD
i. ABI1.3: Calcified vessel, additional diagnostic studies needed
2. Segmental limb pressures
a. Obtained if abnormal ABI measurement is identified
i. 20 mmHg or greater reduction in pressure considered significant for PAD
3. Segmental volume plethysmography
a. Obtained in conjunction with segmental limb pressures to measure the volume change in an organ or limb
b.
Indicated for calcified vessel when the ABI cannot be applied diagnostically
B. Labs
1. Fasting Lipid profile
a. risk assessment of hyperlipidemia
2. Serum glucose
a. risk assessment of DM
3. Coagulation testing
a. risk assessment of hyperviscosity
4. CBC, BUN, creatinine and electrolytes
a. Risk assessment for factors that might lead to worsening peripheral perfusion
5. D-dimer, C-reactive protien, interleukin 6, and homocysteine
a. risk assessment of inflammatory process
6. ECG
a. risk assessment of dysrhythmia, chamber enlargement or MI
C. Imaging
1. Duplex ultrasonography and Doppler color-flow imaging for assessment of stenosed segments and lesion severity
a. Primary noninvasive study to determine flow status
2. MRA, coupled with 3D reconstruction for localization of occluded lesions
a. Highly sensitive and specific
b. Gold standard for diagnosis of PAD
VII. Medical management
A. Medication
1. Antiplatlets
a. Modify atherogenesis to help prevent complications from coronary syndromes and TIA’s
b. Lessen symptoms moderately
i. Aspirin ii. Aspirin and Dipyridamole iii. Clopidogrel iv. Ticlopidine
2. Phosphodiesterases
a. Symptom management
b. Adjunct to supervised physical therapy or
training
c. Pain management and maximizes walking distances by 40-60%
i. Cilostazol
(a) Contraindicated in heart failure
B. Referral
1. Vascular Specialist or Surgeon
a. Recommended in patients with rest pain, functional disability from pain, ABI 0.50 at rest, or any physical signs of lib ischemia or gangrene
VIII. Surgical management
A. Thromboendarterectomy with bypass grafting
1. Indications
a. Lifestyle-limiting claudication with failure of exercise and pharmacologic therapy
2. Procedures
a. Surgical removal thrombus and sclerosed portion of artery and replacing with a graft
3. Risks
a. Artery damage
b. Thrombosis or Embolism
c. Hemorrhage
d. Graft rejection
i. Patient must be >50 to prevent, as younger people more likely to reject graft
e. Infection
f. Loss of limb
g. Death
4. Benefits
a. Increased perfusion
b. Decrease ischemic pain
c. Decrease complications of PAD
B. Percutaneous Transluminal Angioplasty
1. Indications
a. Class A iliac and femoro-popiliteal arterial lesions
b. Lifestyle-limiting claudication with failure of exercise and pharmacologic therapy
2. Procedures
a. Stent placement
3. Risks
a. Arteriostenosis
b. Artery damage
c. Thrombosis or Embolism
d. Hemorrhage
e. Infection
f. Loss of Limb
g. Death
4. Benefits
a. Increased perfusion of ischemic limb
b. Decrease in ischemic pain
c. Decreased risk of complications from PAD
C. Amputation
1. Indications
a. Uncontrolled infection
b. Unrelenting rest pain
c. Progressive gangrene
2. Procedures
a. Amputation of extremity as distal as possible, preserving the knee for optimal use with prosthesis
3. Risks
a. Thrombosis or Embolism
b. Hemorrhage
c. Infection
d. Death
4. Benefits
a. PAD symptom improvement
IX. Emergency management
A. Acute Limb Ischemia
1. Admit
2. Anticoagulate
a. Unfractionated heparin 5000 IU bolus, then 1000 IU/hour infusion
3. Manage Pain
a. morphine 2 mg intravenously, as needed
4. Stabilize Medically
5. Determine severity of ALI
a. Salvageable
i. Angiography to determine surgical management
(a) Endovascular therapy and thrombolysis
(b) Surgery Thrombolectomy/Bypass
b. Nonsalvageable
i. Amputation
X. Patient education/ maintenance/ prevention
A. Lifestyle modifications
1. Exercise
a. 35-50 minute exercise-rest-exercise pattern 3 to 4 times a week
2. Tobacco cessation
a. Counseling and support
b. Medication
3. Diet
4. Wight management
a. BMI 18.5-24.9
b. Waist circumference