Arterial

PAD ➔ Arterial occlusion

PAD & Acute Arterial Occlusion

Patho

Major RF: atherosclerosis; smoking, DM, dyslipidemia likely synergistic

    • Atherosclerotic plaques ➔ narrowing of arteries and eventually ➔ occlusion

    • ↓ blood flow ➔ ischemia ➔ pain and malnourished tissue ➔ skin changes

  • Intermittent claudication

    • ↑ demand (exercise) ➔ ↑ ischemia ➔ ↑ pain (transient/relieved with rest)

SSX

  • Up to 50% of pts are ASX

  • ↓ pulses in affected extremity, bruit on auscultation

  • Femoral & popliteal MC ➔ thigh & calf pain

    • ↑ pain/↓ perfusion when supine (elevation ➔ rubor)

    • relieved when foot hung off bed (dependent ➔ pallor)

  • Trophic changes

    • ↓ temperature, ↓ sweating

    • Thin/shiny/pale skin with ↓ hair

    • Thick/brittle nails

  • Leriche's syndrome

    • Occlusion at bifurcation or both iliac arteries

      • Bilateral butt/hip/thigh pain, impotence, ↓ femoral pulses

  • Advanced disease:

    • Livedo reticularis (net like red-blue pattern)

    • Ulcers ➔ gangrene

      • Typically at pressure points (tips of toes), lateral malleolus

      • Punched out, well defined margins

  • DVT pain can ↑ with walking but is swollen/warm/erythematous

  • Leriche's can present like spinal stenosis (neurogenic claudication)

    • Pain improves with lumbar flexion in spinal stenosis

  • Diabetic neuropathy ➔ glove & stocking (symmetrical) distribution & normal ABI

DX

  • Ankle-brachial index (ABI)

  • Usually 1:1 or ankle slightly ↑

    • > 1.2 = sclerotic/calcified vessels don't compress

    • Normal Ankle/Brachial index = 1 - 1.2

    • 0.9 - 0.4 = Mild - Moderate PAD

    • < 0.4 = severe PAD (associated with pain at rest)

    • Non-compressible (hardened) arteries ➔ > 1.2

  • Arteriography (gold standard) before revascularization surgery

  • Ankle-brachial index (ABI): ratio of ankle systolic BP to brachial systolic BP

    • SUPINE PT, in all 4 extremities, using doppler

      • Ankle (dorsalis pedis or posterior tibialis, whichever is highest)

      • Brachial (right or left arm, whichever is highest)

        • Ankle SBP / Brachial SBP = ABI

TX

  • Lifestyle modification - stop smoking and exercise (yea, cuz it's that easy...)

    • Fixed walking intervals until claudication begins, rest, go again

  • ASA for ↓ M&M associated with ASCVD

  • Anti-platelets: cilostazol (PDE inhibitor)

  • Revascularization if meds fail or critical limb ischemia

    • Percutaneous transluminal angioplasty (PTA), endarterectomy, bypass with autologous vein

  • So, when you ask the fall pt if they're on any medications and they say cilostazol for their painful legs...

  • Google it real quick because you might get a talking to for not calling a trauma alert (cuz you're supposed to know every possible thinner)

Acute Arterial Occlusion

  • ↓ perfusion

    • 6 P's 🙄

      • Early paresthesia (pins & needles) ➔ paralysis (late) , pallor (pale), pulseless, poikilothermic (cold/warm when shouldn't be), pain

  • VASCULAR EMERGENCY

    • 0-6 hrs: Pain, neurosensory deficit

    • 6-12 hrs: Mottled, blanchable

    • 12+ hrs: (irreversible damage) Coalesced capillary pooling, un-blanchable, red & tender

  • DX: bedside doppler, CT angiography

  • TX: salvage limb - IV heparin, surgical embolectomy or thrombolytics

  • Idk... I feel like you can get to the 6 P's if you understand what happens to tissue when it isn't perfused