Peripheral Vascular Disease

Douglas E. Joseph • Hemantha K. Koduri

QUESTIONS

1.A 53-year-old man with a history of obesity, obstructive sleep apnea, hypertension, and hypercholesterolemia presents to the clinic complaining of a nonhealing ulcer on his left ankle present for the past month. His blood pressure is 160/78 mmHg. His physical examination is remarkable for mild bilateral lower leg edema as well as lipodermatosclerosis and hyperpigmentation around the ankles. A mildly tender, superficial ulceration is observed with an irregular pink base above his medial malleolus. His feet and toes are warm, pink, and have 2-second capillary refill and intact sensation. Laboratory tests on this patient include a random blood sugar of 160 mg/dL, creatinine of 1.1 mg/dL, calcium of 10.4 mg/dL, phosphorus of 4.4 mg/dL, and serum intact parathyroid hormone level of 50 pg/mL. What is the most likely etiology of the ulceration?

a.Diabetes mellitus

b.Chronic venous insufficiency

c.Peripheral arterial disease (PAD)

d.Calciphylaxis

e.Brown recluse spider bite

2.A 49-year-old woman with a 60-pack per year history of smoking presents to the emergency department (ED) with complaints of constant, worsening right foot pain and tingling in the toes for several hours. She denies a history of trauma. On examination, she is in moderate distress from pain and has a regular cardiac rhythm at a rate of 104 bpm. Her right lower extremity has a palpable femoral pulse and cool, pale foot with nonpalpable pedal pulses. There is a faint dorsalis pedis arterial signal with continuous-wave handheld Doppler evaluation. Strength is intact in the foot and toes, but she reports pain during examination. What is the most appropriate next step?

a.Admit to the hospital; begin a heparin infusion and antiplatelet therapy. Obtain an urgent echocardiogram to identify the source of embolism.

b.Obtain urgent ankle–brachial indices (ABIs) and pulse volume recordings to determine the severity of disease and begin aggressive risk-factor–modifying medical therapy.

c.Admit to the hospital for an urgent diagnostic abdominal aortogram with runoff and potential endovascular revascularization.

d.Admit to the hospital for pain control and obtain a lumbar magnetic resonance imaging to evaluate for lumbar canal stenosis and pseudoclaudication.

e.Obtain ABIs at rest and with exercise to assess for lower extremity PAD and a venous plethysmography of the lower extremities with exercise to evaluate for venous claudication.

3.A 65-year-old man presents with progressive, short-distance, intermittent claudication in his right leg and a declining ABI. He undergoes an abdominal aortic angiogram with runoff demonstrating a discrete 90% stenotic lesion of the superficial femoral artery. Percutaneous transluminal angioplasty followed by placement of a self-expanding nitinol mesh stent is performed with good post-procedural angiographic results. Which of the following is the most appropriate post-procedure surveillance program for this patient?

a.Regular visits with assessment for interval change in symptoms, vascular examination, and ABI measurement beginning in the immediate post-procedure period and at intervals for at least 2 years

b.Regular visits with assessment for interval change in symptoms, vascular examination, and arterial duplex at 1 month, 3 months, and at month 12

c.Regular visits with assessment for interval change in symptoms, vascular examination, and ABI measurement at 3 months, 6 months, 9 months, and at month 12

d.Regular visits with assessment for interval change in symptoms, vascular examination, and arterial duplex at 3 months, 6 months, 12 months, and 2 years

e.Annual visits with assessment for interval change in symptoms, vascular examination, ABI measurement, and arterial duplex

Case 1 (Questions 4 and 5)

A 59-year-old morbidly obese woman is admitted for cholecystectomy and postoperatively is placed on deep venous thrombosis (DVT) prophylaxis with mini-dose subcutaneous heparin. On hospital day 2, a peripherally inserted central venous catheter is placed in the right arm. The patient is discharged to a rehabilitation facility on hospital day 5 after removal of the venous catheter. Two days later she presents to the emergency room with right upper extremity pain and swelling. She reports she has not felt well enough to participate with physical therapy since being discharged from the hospital. Venous duplex of the right arm demonstrates acute thrombosis of the right cephalic vein. Complete blood count (CBC) and chemistries are within normal range with a platelet count of 180 K/μL.

4.What is the most appropriate management of this patient?

a.Admit to the hospital and start on intravenous (IV) anticoagulation with heparin or a direct thrombin inhibitor (DTI).

b.Prescribe enoxaparin 1 mg/kg every 12 hours and coumadin. Admit for 4 to 5 days of overlap and discontinue enoxaparin once the international normalized ratio (INR) is within therapeutic range for 2 consecutive days. Continue anticoagulant therapy for 3 months.

c.Prescribe enoxaparin 1 mg/kg every 12 hours and coumadin. Discharge with instructions for 4 to 5 days of overlap and discontinue enoxaparin once the INR is within therapeutic range for 2 consecutive days. Continue anticoagulant therapy for 6 months.

d.Prescribe enoxaparin 1 mg/kg every 12 hours and coumadin. Discharge with instructions for 4 to 5 days of overlap and discontinue enoxaparin once the INR is within therapeutic range for 2 consecutive days. Continue anticoagulant therapy for 12 months.

e.Warm compresses and nonsteroidal anti-inflammatory drugs for pain.

5.What should the target activated partial thromboplastin time (aPTT) be to achieve optimal efficacy and safety if anticoagulation with a DTI were to be initiated in this patient?

a.An aPTT of 3.0 to 4.0 times the baseline value

b.An aPTT of 2.5 to 3.0 times the baseline value

d.An aPTT of 2.0 to 3.0 times the baseline value

e.An aPTT of 1.5 to 2.0 times the baseline value

Case 2 (Questions 6 to 8)

A 15-year-old man presents to the clinic accompanied by his mother for evaluation of “red hands.” He earned money last winter clearing sidewalks of snow and plans to do so again in the upcoming weeks. He reports developing red discoloration of his hands after returning home from the cold. The discoloration persisted for a few minutes until his hands were rewarmed. He denies weakness, paresthesia, pain, or skin lesions. He is otherwise healthy. At the time of consultation, inspection of his hands is unrevealing. Radial and ulnar pulses are 2+/2 bilaterally. The Allen test and reverse Allen test reveal return of color to the hands in 7 seconds bilaterally. His mother reports that she and her mother both have Raynaud phenomenon. The patient’s mother expresses concern that her son may have systemic lupus and she requests further testing.

6.What is the most likely diagnosis?

a.Raynaud disease

b.Raynaud phenomenon

c.Normal physiologic cold response

d.Acrocyanosis

e.Thermal injury

7.Of the following, which is the most appropriate next step to objectively evaluate this patient?

a.Obtain an upper extremity angiogram with selective imaging of the digital vessels and before and after administration of nitroglycerin.

b.Obtain digital pulse volume recordings and transcutaneous partial pressure of oxygen measurements of the digits.

c.Order a C-reactive protein level, erythrocyte sedimentation rate, and perform nailfold capillaroscopy.

d.Order a C-reactive protein level, erythrocyte sedimentation rate, and plasma homocysteine level.

e.Order antinuclear antibodies, erythrocyte sedimentation rate, and perform nailfold capillaroscopy.

8.When would be the most appropriate time to schedule a follow-up appointment?

a.5 years

b.3 years

c.2 years

d.1 year

e.As needed

Case 3 (Questions 9 and 10)

A 49-year-old man presents to the clinic with complaints of progressive exertional dyspnea for several weeks. His speech is mildly breathless. Neck veins are distended bilaterally and there is moderate lower extremity edema. He denies chest pain. Electrocardiogram (ECG) shows sinus tachycardia without ST-segment abnormality. Physical examination reveals a parasternal heave and systolic ejection murmur. Past medical history is significant for splenectomy after a car accident several years ago.

9.Which of the following will most accurately confirm the underlying cause of this patient’s symptoms?

a.Chest computed tomography (CT) with IV contrast

b.Transthoracic echocardiogram

c.Transesophageal echocardiogram

d.Pulmonary arteriogram

e.Ventilation–perfusion scan

10.Which of the following statements is most accurate concerning this patient’s underlying diagnosis?

a.Inflammatory mechanisms have not been implicated in the pathogenesis.

b.Patients should be anticoagulated with a vitamin K antagonist and target INR of 2.5 to 3.5.

c.IV epoprostenol is an effective therapy in patients with advanced disease.

d.Inhaled iloprost has been demonstrated to improve exercise capacity.

e.Bosentan has been shown to improve exercise capacity in patients with mild-to-moderate liver disease.

11.You are consulted for recommendations regarding a deep vein thrombosis in a patient who is status post aortic valve replacement with a bioprosthetic valve 4 days prior. Earlier on the day of consult he complained of pain and was diagnosed with a partially occlusive left femoral vein thrombosis. His postoperative course has been otherwise uncomplicated. On examination, the patient is tender around the surgical site. There is moderate pitting edema in the legs bilaterally. He has palpable pulses in all extremities. What do you recommend?

a.Bolus subcutaneous low-molecular-weight heparin (LMWH) 80 mg/kg, then dose at 1 mg/kg subcutaneously every 12 hours

b.Placement of a retrievable inferior vena cava filter

c.Catheter-directed thrombolysis

d.Begin a DTI

e.Begin a weight-based unfractionated heparin infusion

12.A patient with a history of heparin-induced thrombocytopenia (HIT) 8 years ago presents to your office for preoperative evaluation for bioprosthetic aortic valve replacement and coronary artery bypass grafting. He requires anticoagulation while on cardiopulmonary bypass pump during surgery. A recent ELISA (enzyme-linked immunosorbent assay) antiplatelet factor-4 antibody test is negative (<0.400 optical density). He has had no subsequent heparin exposures over the last 8 years. What is the most appropriate anticoagulation regimen you should recommend for this patient?

a.Administration of IV fondaparinux intraoperatively with subsequent daily monitoring of platelet counts

b.Administration of IV LMWH intraoperatively with subsequent daily monitoring of platelet counts

c.Administration of IV argatroban intraoperatively with subsequent daily monitoring of platelet counts

d.Administration of IV hirudin intraoperatively with subsequent daily monitoring of platelet counts

e.Administration of IV unfractionated heparin intraoperatively with subsequent daily monitoring of platelet counts

13.A patient comes to your office 1 month after a hospital stay for gastric bypass surgery. She was diagnosed with a mesenteric vein thrombosis postoperatively. She denies a prior history of venous thromboembolism (VTE). She and her husband have questions about the duration of anticoagulant therapy. They bring copies of laboratory results showing she was checked for a hypercoagulable condition. One laboratory test indicates she is heterozygous for a mutation of the methylenetetrahydrofolate reductase (MTHFR) enzyme. All other laboratory tests are within normal range. She asks you how these results impact duration and intensity of anticoagulation. The most accurate reply is

a.all first-episode DVTs are treated similarly; thus, the discovery of this genetic mutation is of doubtful clinical significance.

b.given the clinical circumstances the laboratory finding is of doubtful clinical significance and you advise she should be anticoagulated with a vitamin K antagonist for 3 months with a target INR of 2.0 to 3.0.

c.she should be anticoagulated with a vitamin K antagonist for 3 months with an increased target INR of 2.5 to 3.5 because of increased thrombogenicity induced by the genetic mutation.

d.she should be anticoagulated with a vitamin K antagonist with a target INR of 2.0 to 3.0 for an extended duration of therapy to 6 months because of increased thrombogenicity induced by the genetic mutation.

e.she should be anticoagulated with a vitamin K antagonist with an INR target of 2.0 to 3.0 indefinitely because of the high rate of recurrent VTE associated with the heterozygous form of this genetic mutation.

14.A 34-year-old woman with a history of deep vein thrombosis who is chronically anticoagulated with warfarin discovers she is pregnant. Her due date is 34 weeks from now. Currently, she is on warfarin and has an INR of 2.2. She presents to the clinic for recommendations regarding her anticoagulation management. Which of the following is true regarding venous thromboembolic disease, anticoagulation therapy, and pregnancy?

a.When deep vein thrombosis of the lower extremities complicates a pregnancy, the right leg is affected significantly more often than the left, presumably because of exaggeration of the compressive effects of the left iliac artery compressing on the right iliac vein during pregnancy.

b.The incidence of teratogenic complications of pregnancy caused by warfarin, including nasal hypoplasia and stippled epiphyses, is greatest if warfarin exposure occurs during weeks 14 through 24.

c.Warfarin is contraindicated in the nursing mother because of a high incidence of inducing an anticoagulant effect in the infant fed with breast milk from a mother on warfarin therapy.

d.Fatal pulmonary embolism is a leading cause of maternal mortality in the Western world.

e.LMWHs have been proven safe and efficacious in pregnant woman with prosthetic heart valves, and supplanted unfractionated heparin as the standard of care in this setting.

Case 4 (Questions 15 and 16)

A 65-year-old man presents to the clinic with complaints of episodic burning pain involving the soles of his feet and toes. He reports symptoms are most severe when the weather becomes hot and generally occurs when he is outside in the heat. His feet and toes turn red and feel hot to touch during episodes. When he returns to an air-conditioned area, symptoms begin to dissipate or some episodes may take hours for complete resolution. Elevating his legs relieves symptoms as does walking barefoot on cold tile floors. His past medical history includes hypertension, well controlled with atenolol, and he takes once daily low-dose aspirin for primary prevention.

Physical Examination

Blood pressure is 120/70 mmHg and pulse is 84 bpm.

The cardiac and lung examinations are normal.

The abdomen is soft and nontender with a normal-sized palpable aortic pulsation.

No bruit can be heard over the neck, abdomen, or either groin.

Radial, dorsalis pedis, and posterior tibial pulses are 2+/2 bilaterally.

A mild erythema and increased warmth are noted in toes and soles of the feet.

15.Which of the following is the most likely diagnosis?

a.Heat urticaria

b.Erythromelalgia

c.Chilblains (perniosis)

d.Raynaud phenomenon

16.What laboratory values should be followed serially in patients with this condition?

a.Electrolytes, blood urea nitrogen, and creatinine

b.Erythrocyte sedimentation rate

c.Ionic calcium

d.Complete blood count with differential (CBC with diff)

17.A 17-year-old boy was involved in a motor vehicle accident, which resulted in multiple fractures as well as internal injuries that necessitated multiple abdominal surgeries over a 2-week period. He is expected to recover fully. An intraluminal filling defect was incidentally identified consistent with DVT of the right external iliac vein on a contrast-enhanced abdominal CT scan. Anticoagulation was contraindicated because of a retroperitoneal hemorrhage. It was determined that placement of an inferior vena cava filter was necessary. Of the following types of filters, which filter is most appropriate in this case?

a.Bird’s Nest vena cava filter

b.Gunther Tulip retrievable vena cava filter

c.TrapEase inferior vena cava filter

d.Greenfield vena cava filter

e.Simon Nitinol inferior vena cava filter

Case 5 (Question 18)

You are called to the bedside of a 68-year-old man in mild distress who underwent cardiac catheterization earlier in the day. He is complaining of increasing right groin pain. He complains of weakness and tingling in his foot and toes. He is presently on a heparin infusion because of atrial fibrillation. On inspection you note a large area of skin in his right groin and proximal thigh to be dark blue and there is a large, palpable, hard pulsatile mass. With ultrasound using color Doppler you note an irregular shaped area of flow measuring 4.0 cm × 3.3 cm near the common femoral artery, approximately 4.0-cm deep and connected to the artery by a 0.5-cm neck. There is surrounding hematoma observed. Spectral waveform analysis of the neck demonstrates a to-and-fro pattern.

18.What is the best treatment option for management of this patient’s condition?

a.Placement of a femoral compression device overnight and analgesics for pain

b.Injection of thrombin by ultrasound guidance

c.Ultrasound-guided compression for 30 minutes

d.Surgical evacuation of the hematoma and suture repair of the artery

e.Placement of a compression dressing with snugly applied bandages around the leg and serial duplex scans to monitor for resolution

19.A 74-year-old man is in the ICU (intensive care unit) recovering from coronary artery bypass surgery and has developed a hemorrhagic pericardial effusion. He is currently stable, but has noted swelling and pain in his left leg. An ultrasound is ordered and reveals acute thrombus in the left peroneal vein. Which of the following is the best management option?

a.No action is required because calf vein thrombus is not clinically important

b.Pneumatic compression stockings and enoxaparin 40 mg every 24 hours

c.Follow up with serial duplex ultrasound scans

d.Initiate a continuous unfractionated heparin infusion

e.Proceed with placement of an inferior vena cava filter

Case 6 (Questions 20 and 21)

A 25-year-old man presents to the clinic with complaints of pain in his feet with walking. He reports this has been going on for several months and has progressively worsened in the past few weeks. He is beginning to develop symptoms in his right calf and earlier this week noticed a black area on his great toe. He has no medical problems, takes no medications, and is in good health overall. He is a smoker and works as a computer salesman. He reports a family history of VTE; his mother had a pulmonary embolism at the age of 50 and was diagnosed with the antiphospholipid antibody syndrome.

20.What is the most likely cause of his symptoms?

a.Elevated anticardiolipin antibodies

b.Thromboangiitis obliterans (TAO, Buerger disease)

c.Takayasu arteritis

d.Premature atherosclerosis

e.Livedoid vasculitis (atrophie blanche)

21.What is the most important aspect of therapy for this patient?

a.Anticoagulation with a vitamin K antagonist

b.Cessation of exposure to all forms of tobacco

c.Initiate immunosuppressive therapy with glucocorticoids

d.Antiplatelet therapy with aspirin

e.Admit to the hospital to begin tissue plasminogen activator therapy

Case 7 (Questions 22 and 23)

A 24-year-old woman presents with complaints of a swollen, painful left leg. She has a history of two episodes of deep vein thrombosis in the past. She recalls that they were both on the left side, but is unsure of which veins were involved. She was on warfarin in the past but discontinued it when she began attempting to conceive. Venous duplex demonstrates an acute deep vein thrombosis of the left femoral vein. You initiate treatment with LMWH.

22.What is the most likely diagnosis?

a.Heterozygous prothrombin gene mutation

b.Heterozygous factor V Leiden mutation

c.May-Thurner syndrome

d.Klippel-Trenaunay syndrome

e.Klippel-Trenaunay-Weber syndrome

23.Which of the following is the best management option?

a.Indefinite anticoagulant therapy with warfarin

b.Indefinite monotherapy with enoxaparin

c.Venography for thrombus removal and stent placement

d.Placement of an inferior vena cava filter and discontinue anticoagulants

e.Anticoagulate with either warfarin or enoxaparin for 6 months

24.A 68-year-old gentleman underwent coronary artery bypass surgery using the saphenous vein harvested from his left leg. He has done well postoperatively except for failure of the left leg incision to heal completely. Four months after surgery, his leg is still not fully healed and a peri-incisional ulcer is now present. He has significant edema in his leg, which was present prior to surgery. There are no symptoms or physical findings suggestive of infection. His ABI is 0.94 on the right and 0.89 on the left. You order an ultrasound, which is negative for acute thrombus but does reveal significant venous valvular incompetence in the deep veins. Which of the following is most likely to improve this patient’s wound healing?

a.Whirlpool therapy

b.Antibiotics and topical steroids

c.Compression stockings

d.Plastic surgery consult

e.Revascularization

25.You are providing postoperative care for a patient who is in the cardiovascular surgery postoperative ICU, status post coronary artery bypass surgery. A venous duplex ultrasound was performed to evaluate for new-onset bilateral leg swelling. Results are reported as negative for DVT, but with monophasic flow noted within the bilateral common femoral veins. Which of the following is the next best step?

a.CT venogram of the lower extremities

b.CT venogram of the abdomen and pelvis

c.Enoxaparin therapy 1 mg/kg subcutaneous injections every 12 hours

d.Enoxaparin therapy 40 mg subcutaneous injections every 24 hours

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