Updated: 5/22/2019

Arterial Insufficiency

Topic
Review Topic
0
0
Questions
8
0
0
Evidence
4
0
0
Snapshot
  • A 50-year-old man presents to his primary care physician for pain in his lower legs with long walks. He reports walking 10 blocks before feeling the pain and that it resolves with rest. His medical history includes hyperlipidemia, hypertension, and diabetes. His blood pressure is 145/80 mmHg, pulse is 90/min, and respirations are 18/min. On physical exam, his distal pulses are faint. His bilateral calves are dry and hairless with no peripheral ulcers. His skin is cool to the touch, especially in his feet. An ankle-brachial index is performed.
Introduction
  • Clinical definition
    • ischemia resulting from obstruction of the peripheral arteries
  • Epidemiology
    • demographics
      • affects older patients
      • male > female
    • location
      • most commonly affects the popliteal artery
    • risk factors
      • smoking
      • hypertension
      • hyperlipidemia
      • family history
      • renal disease
      • diabetes
  • Etiology
    • most commonly caused by atherosclerosis
      • peripheral artery disease
  • Pathogenesis
    • atherosclerotic disease can lead to progressive obstruction of the peripheral arteries
      • lack of blood flow ischemia, leading to pain
  • Associated conditions
    • Leriche syndrome
      • aortoiliac occlusion presents with
        • bilateral lower limb claudication
        • impotence
        • lower extremity muscular atrophy
    • coronary artery disease
Presentation
  • Symptoms
    • progressive severity
      • asymptomatic
      • intermittent claudication 
      • pain at rest
      • nonhealing wounds
      • ulceration
      • gangrene and threatened limb
    • calves are the most commonly affected area
  • Physical exam
    • may have ischemic ulcers
      • often starts as a traumatic wound that fails to heal
      • often involves the foot
    • may have skin changes
      • pale or red
      • dry, shiny, and hairless in severe disease
      • cool to touch
Imaging
  • Doppler ultrasound
    • indication
      • further evaluation of extent of vascular disease
    • findings
      • low-velocity flow through the artery
Studies
  • Ankle-brachial index
    • less than or equal to 0.9 is diagnostic for peripheral artery disease
    • best initial test
  • Making the diagnosis
    • based on clinical presentation
Differential
  • Arterial aneurysm
    • distinguishing factors
      • normal ankle-brachial index
      • aneurysm seen on imaging
  • Embolism (pain, pallor, paresthesias, poikilothermia, paralysis, pulselessness)
    • distinguishing factor
      • acute progression of symptoms
    • treatment 
      • heparin
      • vascular surgery
Treatment
  • Management approach
    • initial management includes anti-platelet therapy as well as optimizing treatment for underlying conditions, such as hypertension and hyperlipidemia
  • Conservative 
    • cessation of smoking 
      • indication
        • all patients
    • regular exercise regimen
      • indication
        • all patients
  • Medical
    • anti-platelet agents 
      • indication
        • all patients
      • drugs
        • aspirin
        • clopidogrel
  • Operative
    • revascularization
      • indication
        • claudication refractory to medical therapy
      • modalities
        • bypass surgery
        • angioplasty and stenting
    • amputation
      • indication
        • most severe cases in which limb is not salveagable
Complications
  • Osteomyelitis
  • Loss of limb
  • Cardiovascular event
 

Please rate topic.

Average 4.8 of 6 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (8)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M2.CV.4690) A 65-year-old man with a past medical history of anterior myocardial infarction, peripheral arterial disease, and known patent foramen ovale presents to the emergency department after being found down from a fall on the sidewalk in the middle of winter. He states that his right leg feels numb and painful at the same time. He insists that he did not slip on ice or snow, yet fell suddenly. He is taking aspirin, simvastatin, and cilastazol. Vital signs show T 98.0 F, BP 100/60, HR 100, RR 18. His pulse is irregularly irregular. His right leg appears pale with no dorsalis pedis and posterior tibial pulses compared to 2+ pulses on the left. He cannot discern soft or sharp touch in his right leg. Which intervention will most likely improve the viability of this patient's right leg? Review Topic

QID: 107590
1

Percutaneous transluminal stent implantation

0%

(0/0)

2

Rivaroxaban

0%

(0/0)

3

Warfarin

0%

(0/0)

4

Catheter-based thrombectomy / thrombolysis

0%

(0/0)

5

Heparin

0%

(0/0)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 4

You have 100% on this question.
Just skip this one for now.

(M2.CV.70) A 63-year-old man presents to the clinic complaining of burning bilateral leg pain which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. His past medical and surgical history are significant for hypertension, hyperlipidemia, diabetes, and a 40-pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 167/108 mm Hg, pulse is 88/min, respirations are 13/min, and oxygen saturation is 95% on room air. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally. Which of the following is the best initial treatment for this patient's symptoms? Review Topic

QID: 100586
1

Balloon angioplasty with stenting

86%

(72/84)

2

Exercise and smoking cessation

5%

(4/84)

3

Femoral-popliteal bypass

1%

(1/84)

4

Lisinopril and atorvastatin

1%

(1/84)

5

Lovenox and atorvastatin

6%

(5/84)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 2
ARTICLES (4)
Topic COMMENTS (20)
Private Note