General Surgery Rotation

General Surgery: Peripheral arterial disease

Patient will present as → a 63-year-old male complaining of bilateral leg pain, which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. Past medical and surgical history is significant for hypertension, hyperlipidemia, and coronary artery bypass graft (5 years ago). He has a 60-pack-year smoking history. Vital signs are as follows: Temp 37C, HR 70, BP 143/89, and RR 18. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally; they are warm and well perfused. Ankle-brachial indices are 0.7 and 0.8.

Ulcers from arterial insufficiency are painful or painless?
Painful

PAD is most commonly the result of atherosclerosis and is a significant independent risk factor for cardiovascular and cerebrovascular morbidity and mortality

  • Lower extremity atherosclerotic PAD is initially asymptomatic but typically progresses to claudication, ischemia, and pain with exercise
  • Acute arterial occlusion may be caused by thrombosis or embolism
  • Thrombotic disease also may be a result of trauma, hypovolemia, inflammatory arteritis (including Takayasu arteritis and Buerger disease), polycythemia, dehydration, repeated arterial punctures, and hypercoagulable states

Intermittent claudication, foot or lower leg pain with exercise that is relieved by rest, is usually the first symptom of PAD. As the condition progresses, pain at rest develops.

  • Femoral and distal pulses will be weak or absent; an aortic, iliac, or femoral bruit may be present.
  • Skin changes to the lower extremity include loss of hair, shiny atrophic skin, and pallor with dependent rubor
  • Severe, chronic disease results in numbness, tingling, and ischemic ulcerations, which may lead to gangrene.
  • Acute arterial occlusion threatens limb viability and results in the “6 Ps”: pain, pallor, pulselessness, paresthesias, poikilothermia, and paralysis
Disease Pearls Diagnostics Treatment
Intermittent claudication Occurs distal to the level of stenosis or occlusion

  • dull, aching pain calf pain with walking
  • aggravated by exercise
  • relieved with rest (usually within 10 minutes)
  • cramping
  • numbness, weakness, giving way

Physical

  • Hair loss lower extremities
  • Thinning of skin
  • Diminished pulses

 

An ankle-brachial index (ABI), which uses Doppler measurements to compare the BP in the upper and lower extremities, is a highly sensitive and specific test

  • An ABI of ≤ 0.9 indicates significant disease

Angiography remains the gold standard study

 

Stop smoking first line

  • Graduated exercise - walk to point of claudication, rest, then continue walking
  • Control HTN, DM, weight
  • ASA + clopidogrel
  • Cilostazol

Surgery

  • Angioplasty
  • Bypass grafting
Asymptomatic PAD Screen patients with

Abnormal or absent pedal pulse

Age > 7o

Ages 50-69 with a history of smoking or DM

Asymptomatic

Screen with ABI

  • < 0.9 diagnostic
  • 0.91-1.3 normal, no further testing

 

Preventative treatment: ASA, lipid-lowering, blood pressure control
PAD or PVD Occlusive atherosclerotic disease of lower extremities (noncardiac vessels)

Sites: superficial femoral artery (most common), popliteal, aortoiliac

Risk factors: smoking, hyperlipidemia, DM, HTN

Pain in one or more lower extremity muscle groups

  • Cramping of thigh, calf, or buttocks
  • Intermittent claudication
  • Rest pain - prominent at night (wakes the patient up)

Diminished or absent pulses

  • Muscle atrophy
  • Hair loss
  • Thick toenails
  • Pallor

 

Lipids: hypercholesterolemia >240, hypertriglyceridemia >250

  • Ankle: brachial index (ABI) testing
    • If <0.90 (diagnostic)
  • Doppler: reduced or interrupted flow
  • Arteriography (gold standard)
Prevention of atherosclerosis Control HLD, HTN, weight, DM

Manage primary hyperlipidemia: statins, diet, exercise

Graduated exercise: walk to point of claudication, rest, then continue walking Foot care

Reduce BP

Stop smoking

Most important Medical intervention:

  • ASA + ticlopidine or clopidogrel (symptomatic relief)
  • Cilostazol (PDE inhibitors)

Surgery:

  • Angioplasty (preferred)
  • Adjunctive stenting
  • Bypass grafting

Prognosis: Stable: 70%-80% Worsening: 10%-

What is the gold standard diagnosis for PAD?
Angiography remains the gold standard study.

Doppler ultrasound flow studies can be used to determine systolic pressures in the peripheral arteries.

  • An ankle-brachial index (ABI), which uses Doppler measures to compare the BP in the upper and lower extremities, is a highly sensitive and specific test
    • An ABI of ≤ 0.9 indicates significant disease
  • Angiography remains the gold standard study
  • CT or magnetic resonance angiography is also useful for locating stenotic sites and for accurate diagnosis of thrombosis or embolism.
  • Although not regularly used for screening, elevated homocysteine has a strong association with incidence and progression of PAD.

Aggressive risk factor modification: Tobacco use must be discontinued; diabetes, HTN, and hyperlipidemia must be controlled.

  • Exercise - walking to the point of claudication
  • Platelet inhibitors: Cilostazol, Aspirin, Clopidogrel
  • ACE inhibitors, statins, progressive exercise, and supervised exercise programs have been shown to be helpful at reducing symptoms of claudication
  • If these interventions fail, revascularization with PTA, bypass grafts, stenting
    • Surgical graft bypass
    • Angioplasty—balloon dilation
    • Endarterectomy—remove diseased intima and media
    • Surgical patch angioplasty (place patch over stenosis)
  • Erectile dysfunction may require revascularization or treatment with a phosphodiesterase, such as sildenafil.

osmosis Osmosis
Picmonic
Peripheral artery disease (PAD)

IM_NUR_PeripheralArteryDisease_v1.4_

Peripheral artery disease (PAD) is caused by the narrowing of peripheral arteries, especially those in the legs, due to plaque buildup. Patients with PAD can develop intermittent muscle cramping, arterial ulcers, critical limb ischemia, and paresthesias. If the condition is left untreated, amputation(s) may be necessary to remove the diseased limb(s).

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Question 1
A 76-year-old male with a 5 year history of atrial fibrillation presents to the Emergency Department with an inability to move his left leg. The patient notes that he first noted that his leg "felt funny" about two hours ago, and that it appeared to be more pale than normal. Since the leg started feeling funny, his ability to move it has decreased, to the point where he can no longer move it. He recently ran out of his warfarin, and hasn't taken any in two weeks. On physical exam his vital signs are within normal limits. His neurological exam reveals a pale, painful left leg with absent femoral and dorsalis pedis pulses. He has no other strength deficits and pulses in his right leg and right arm are intact. Which of the following would be the appropriate first action for this patient's condition?
A
Thrombolysis
Hint:
Thrombolysis would be appropriate for a patient with an ischemic stroke.
B
Embolectomy
C
Fasciotomy
Hint:
A fasciotomy might be indicated after this patient's embolectomy, but would not be the initial management for this patient.
D
Amputation
Hint:
An amputation would be premature but may be indicated if the patient developed an infected limb.
E
No intervention necessary
Hint:
This patient has an intervenable condition; thus, an embolectomy would be indicated.
Question 1 Explanation: 
This patient has an embolic occlusion of his left common iliac artery resulting in the pale, painful leg. The appropriate intervention would be an embolectomy to try and remove the occlusion. Patients with atrial fibrillation are at risk for embolic complications, especially patients who abruptly discontinue their anticoagulation. Embolic complications can include stroke or other systemic embolizations. An embolism to the common iliac artery results in a pale, pulseless, painful leg, and requires immediate embolectomy to preserve the limb.
Question 2
Pharmacologic management of peripheral arterial disease includes:
A
Elastic compression stockings
Hint:
Elastic compression stockings should be avoided as it can decrease arterial circulation to the skin.
B
Calcium channel blockers
Hint:
Calcium channel blockers have not proven to be beneficial.
C
Cilostazol
D
Warfarin
Hint:
Warfarin may prevent more cardiovascular events but causes more major bleeding and has not been shown to improve outcomes in those with chronic PAD.
E
Propranolol
Hint:
βblockers are contraindicated in isolated PAD as it will worsen claudication
Question 2 Explanation: 
Cilostazol (a phosphodiesterase inhibitor) increases claudication distance by 40% to 60% in patients with peripheral arterial disease. Elastic compression stockings should be avoided as it can decrease arterial circulation to the skin. Calcium channel blockers have not proven to be beneficial. Warfarin may prevent more cardiovascular events but causes more major bleeding and has not been shown to improve outcomes in those with chronic PAD.
Question 3
A 72-year-old smoker with a positive history of severe degenerative arthritis, diabetes, and CVD presents to your office complaining of bilateral leg pain that occurs after walking 200 yards. He reports that rest improves his symptoms. Which of the following would be appropriate?
A
Ankle/ brachial indices
B
MRI of the lumbar spine
C
Ultrasonography of the lower extremities
D
EMG of the lower extremities
E
Arteriogram of the lower extremities
Hint:
The use of arteriogram is not necessary unless the patient is considering surgery.
Question 3 Explanation: 
Claudication occurs when there is arterial insufficiency of the lower extremities. It usually occurs in the calf muscles, thighs, and buttocks and is bilateral and progressive. Symptoms include pain, fatigue, or weakness associated with the lower legs that typically occurs after walking predictable distances, and, occasionally, impotence in men. If the pain or discomfort occurs with varying distances, a workup for other causes is necessary. Patients who experience significant restriction in their activities may be considered for surgery; however, their overall health status should be considered first. Many patients have underlying CVD that may put them at surgical risk. Ankle/ brachial indices (usually < 0.90 with peripheral arterial disease) are the simplest method to estimate blood flow to the lower extremities. The use of arteriogram is not necessary unless the patient is considering surgery. The Eighth American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy recommends lifelong use of aspirin at a dosage of 75 to 100 mg per day in all patients with intermittent claudication. Clopidogrel (Plavix) is recommended in patients who cannot take aspirin. Cilostazol is recommended only in patients with disabling intermittent claudication who do not respond to risk factor modification and exercise and who are not surgical candidates. The guidelines also recommend against the use of pentoxifylline, prostaglandins, and anticoagulants in patients with intermittent claudication.
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