acute art occlusion low limb - docmus

[ArchivalUser]

which one to do first? heparin/ echo/ embolectomy?

what if post MI?

[ArchivalUser]

post MI HF: should we add warfarin when sending pt home?

[ArchivalUser]

CAN U CLARIFY YOUR QUESTION.

[ArchivalUser]

a pt with p/h/o Afib showing c/f of limb artery occlusion. shld we give heparin first and arrange for arteriogram or first take the thrombi out, determine the source and then treat?

and what if the same case if the pt has no h/o cardiac event?

thanks sami

[ArchivalUser]

If symptomatic limb artery occlusion, we should remove the clot first, then follow by heparin, warfarin which prevent further incidents, right?

Doppler shows clot, ABI ratio lessthan 0.4 severe occlusion.... need prompt removal by arthroplasty, stent.

YOUR Question,
PAD increase the risk of CVS and stroke, TIA. Mostly they have cardiac event.
Even though they dont have AF ( as you said) all basic pato is high lipid and arthrosclerosis, so basically the mx is the same.

These are from wiki.

Diagnosis
Upon suspicion of PVD, the first-line study is the ankle brachial pressure index (ABPI/ABI). When the blood pressure readings in the ankles is lower than that in the arms, blockages in the arteries which provide blood from the heart to the ankle are suspected. An ABI ratio less than 0.9 is consistent with PVD; values of ABI below 0.8 indicate moderate disease and below 0.4 imply severe ischemic disease.

It is possible for conditions which stiffen the vessel walls (such as calcifications that occur in the setting of chronic diabetes) to produce false negatives usually, but not always, indicated by abnormally high ABIs (> 1.3). Such results and suspicions merit further investigation and higher level studies.

If ABIs are abnormal the next step is generally a lower limb doppler ultrasound examination to look at site and extent of atherosclerosis. Other imaging can be performed by angiography,[1] where a catheter is inserted into the common femoral artery and selectively guided to the artery in question. While injecting a radiodense contrast agent an X-ray is taken. Any flow limiting stenoses found in the x-ray can be identified and treated by atherectomy, angioplasty or stenting.

Modern multislice computerized tomography (CT) scanners provide direct imaging of the arterial system as an alternative to angiography. CT provides complete evaluation of the aorta and lower limb arteries without the need for an angiogram's arterial injection of contrast agent.

TreatmentDependent on the severity of the disease, the following steps can be taken

Smoking cessation (cigarettes promote PVD and are a risk factor for cardiovascular disease).
Management of diabetes.
Management of hypertension.
Management of cholesterol, and medication with antiplatelet drugs. Medication with aspirin, clopidogrel and statins, which reduce clot formation and cholesterol levels, respectively, can help with disease progression and address the other cardiovascular risks that the patient is likely to have.
Regular exercise for those with claudication helps open up alternative small vessels (collateral flow) and the limitation in walking often improves. Treadmill exercise (35 to 50 minutes, 3 to 4 times per week[1]) has been reviewed as another treatment with a number of positive outcomes including reduction in cardiovascular events and improved quality of life.

Cilostazol or pentoxifylline treatment to relieve symptoms of claudication.

Treatment with other drugs or vitamins are unsupported by clinical evidence, "but trials evaluating the effect of folate and vitamin B-12 on hyperhomocysteinaemia, a putative vascular risk factor, are near completion".

After a trial of the best medical treatment outline above, if symptoms remain unnacceptable, patients may be referred to a vascular or endovascular surgeon; however, "No convincing evidence supports the use of percutaneous balloon angioplasty or stenting in patients with intermittent claudication".

Angioplasty (PTA or percutaneous transluminal angioplasty) can be done on solitary lesions in large arteries, such as the femoral artery, but angioplasty may not have sustained benefits.**

Plaque excision, in which the plaque is scraped off of the inside of the vessel wall.

Occasionally, bypass grafting is needed to circumvent a seriously stenosed area of the arterial vasculature. Generally, the saphenous vein is used, although artificial (Gore-Tex) material is often used for large tracts when the veins are of lesser quality.

Rarely, sympathectomy is used - removing the nerves that make arteries contract, effectively leading to vasodilatation.

When gangrene of toes has set in, amputation is often a last resort to stop infected dying tissues from causing septicemia.

Arterial thrombosis or embolism has a dismal prognosis, but is occasionally treated successfully with thrombolysis.

Hope it helps.