Atherosclerosis and Intermittent Claudication
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Questions and Answers

What is the most common location of pain in intermittent claudication?

  • Feet
  • Calf (correct)
  • Thighs
  • Buttocks

    • Which of the following is a risk factor for atherosclerosis, leading to endothelial injury?

  • Glycosaminoglycans (GAG)
  • Low-density lipoprotein (LDL) (correct)
  • High-density lipoprotein (HDL)
  • Tissue thromboplastin

    • What is the result of proliferation of smooth muscle cells in atherosclerosis?

  • Thickening of arterial wall (correct)
  • Narrowing of arterial lumen
  • Increase in blood flow
  • Decrease in blood pressure

    • What is the term for the subgroup of patients with symptomatic lower extremity arterial disease in which the ischemic process endangers part or all of the lower extremity?

    <p>Critical leg ischemia</p> Signup and view all the answers

    What is the result of plaque formation and plaque fracture in atherosclerosis?

    <p>Thrombosis</p> Signup and view all the answers

    What is the characteristic of pain in intermittent claudication?

    <p>Pain that develops with exercise and is relieved with rest</p> Signup and view all the answers

    What is the site of LDL influx and binding in atherosclerosis?

    <p>Sub-endothelium</p> Signup and view all the answers

    What is the term for the condition where the ischemic process does not endanger the lower extremity?

    <p>Asymptomatic arterial insufficiency</p> Signup and view all the answers

    What is the primary difference in the site of occlusion between embolism and thrombosis?

    <p>Embolism occurs in normal vessels, while thrombosis occurs on top of a stenosis</p> Signup and view all the answers

    What is the primary difference in the onset of symptoms between embolism and thrombosis?

    <p>Embolism has a sudden onset, while thrombosis has a gradual onset</p> Signup and view all the answers

    What is the primary difference in the presence of previous complaints between embolism and thrombosis?

    <p>Embolism rarely has previous complaints, while thrombosis often has previous complaints</p> Signup and view all the answers

    What is the primary difference in the angiographic findings between embolism and thrombosis?

    <p>Embolism shows no or minimal atherosclerosis, while thrombosis shows diffuse atherosclerosis</p> Signup and view all the answers

    What is the primary factor that determines the degree of ischemic tissue damage?

    <p>All of the above</p> Signup and view all the answers

    What is the earliest tissue to be affected by ischemia?

    <p>Nerves</p> Signup and view all the answers

    What is the primary mechanism of cellular ischemia during revascularization?

    <p>Accumulation of oxygen free radicals</p> Signup and view all the answers

    What is the primary complication of muscle infarction?

    <p>Myoglobinuria and acute renal failure</p> Signup and view all the answers

    Which of the following is a type of arteritis?

    <p>Takayasu syndrome</p> Signup and view all the answers

    What is the main cause of chronic arterial occlusive disease of the extremities?

    <p>Atherosclerosis</p> Signup and view all the answers

    What is the prevalence rate of intermittent claudication in women above 50 years?

    <p>2.5%</p> Signup and view all the answers

    What is the consequence of peripheral sensory neuropathy in diabetics?

    <p>Traumatic ulceration</p> Signup and view all the answers

    What is the consequence of smoking in relation to lower extremity arterial disease?

    <p>It increases the risk of disease</p> Signup and view all the answers

    What is the characteristic of intermittent claudication?

    <p>Pain that develops with exercise and is relieved with rest</p> Signup and view all the answers

    What is the association between hypertension and lower extremity arterial disease?

    <p>There is a positive correlation</p> Signup and view all the answers

    What is the consequence of a fasting cholesterol level >270 mg/dL?

    <p>It doubles the incidence of intermittent claudication</p> Signup and view all the answers

    Study Notes

    Arteritis

    • Examples of arteritis include:
    • Thrombangitis obliterance (Burger's disease)
    • Rheumatoid arthritis
    • Systemic lupus erythematosis
    • Scleroderma
    • Kawasaki syndrome
    • Takayasu syndrome

    Vasospastic Diseases

    • Examples of vasospastic diseases include:
    • Reynaud's disease
    • Reynaud's phenomena

    Risk Factors

    • Age: incidence of lower extremity arterial disease increases with age
    • Male Gender: higher prevalence of intermittent claudication in men
    • Diabetes Mellitus and Impaired Glucose Tolerance: increased risk of lower extremity amputation
    • Smoking: strong risk factor for development of lower extremity arterial disease
    • Hypertension: linked to lower extremity arterial disease
    • Hyperlipidemia: associated with a doubling of the incidence of intermittent claudication

    Atherosclerosis

    • Most common cause of chronic arterial occlusive disease of the extremities
    • Arterial narrowing reduces blood flow to the lower limb > upper limbs
    • Intermittent claudication: pain that develops in the affected limb with exercise and is relieved with rest
    • Pain usually occurs distal to the arterial narrowing or obstruction
    • Superficial femoral and popliteal arteries are most commonly affected
    • Distal aorta and its bifurcation are the next most frequent sites of involvement

    Pathogenesis

    • Endothelial injury theory:
      • Injury leads to altering of normal homeostatic properties of endothelium
      • LDL influx and binding to Glycosaminoglycans (GAG) in the sub-endothelium
      • Modified form of LDL produces inflammatory response
      • Proliferation of smooth muscle cells → thickening of arterial wall → narrowing of arterial lumen
      • Diffusion of free cholesterol into extracellular spaces
      • Plaque formation and plaque fracture → tissue thromboplastin → thrombosis

    Clinical Picture

    • Symptoms:
      • Asymptomatic arterial insufficiency
      • Symptomatic disease presenting as intermittent claudication
      • Rest pain increases at night, decreases by dependency and rubbing
      • Critical leg ischemia, which defines the subgroup of patients with symptomatic lower extremity arterial disease in which the ischemic process endangers part or all of the lower extremity

    Thrombosis vs Embolism

    • Onset:
      • Thrombosis: acute
      • Embolism: sudden
    • Site:
      • Thrombosis: on top of a stenosis, calcified
      • Embolism: normal vessels, soft
    • Previous complaint:
      • Thrombosis: symptoms of chronic ischemia
      • Embolism: rare
    • Findings:
      • Thrombosis: evidence of peripheral arterial disease
      • Embolism: normal pulses
    • Multiplicity:
      • Thrombosis: single site
      • Embolism: multiple sites
    • Angiography:
      • Thrombosis: diffuse atherosclerosis, tapered and irregular cut off, developed collaterals
      • Embolism: no or minimal ASO, sharp cut off (Fontaine sign), multiple occlusions, no collaterals

    Pathophysiology

    • Depends on:
      • Degree of obstruction (complete or partial)
      • Site of occlusion
      • Presence of collaterals
      • Affected tissues
    • Sluggish circulation distal to the occlusion → secondary thrombosis → occlusion of collaterals
    • Different tissues can tolerate ischemia at different rates:
      • Brain and heart: most sensitive
      • Skin, subcutaneous, and muscles: less sensitive
    • Nerves: first to be affected (irreversible damage after 6 hours)
    • Muscles: more tolerant (up to 6-10 hours)
    • Skin: last to show necrosis
    • Cellular ischemia:
      • Alteration of cell wall permeability → Na+ and water influx → intra and extracellular edema → compartment syndrome
      • Release of K+ → hyperkalemia → cardiac arrest
      • Release of myoglobin after muscle infarction → precipitate in renal tubules → myoglobinuria and acute renal failure
    • Accumulation of acidic products of anaerobic metabolism → metabolic acidosis
    • During reperfusion, oxygen free radicals accumulate → cellular insult and necrosis

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    Description

    This quiz covers the effects of atherosclerosis on blood vessels, particularly the femoral and popliteal arteries, and the resulting symptoms of intermittent claudication.

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