2- peripheral vascular disease

Question 1

what is intermittent claudication?

Answer 1

cramping in legs when walking - because when patient walking leg can’t get enough oxygen (it’s often the first symptom of PVD)

Question 2

why is intermittent poorly diagnosed?

Answer 2

it can mimic lots of other things

Question 3

what are the lower limb arteries?

Answer 3

aorta →iliac arteries →common femoral at the groin →profunda femoris (end artery that goes deep into thigh), deep femoral, superficial femoral →popliteal →posterior tibia (→peroneal tibial artery), anterior artery →dorsalis pedis (pedal arch)

Question 4

what does intermittent claudication pain present like? (e.g. when does it come on, when is it relieved etc)

Answer 4

• pain (cramp like) on walking
• muscle groups distal to blocked artery affected
• no pain at night & at rest
• quickly relieved at rest
• usually comes on after same distance each time

Question 5

what are other conditions that could have intermittent claudication as a syptom?

Answer 5

OA (osteoarthritis), spinal canal stenosis (narrowing of spinal canal), lumbar nerve root irritation

Question 6

what are the outcomes like for intermittent claudication?

Answer 6

mostly people improve or are stable (66%)
some people deteriorate (27%)
a small proportion lead to amputation (2-7 %)

Question 7

does intermittent claudication lead to limb loss?

Answer 7

in itself it’s no threat to the limb but treatment may not prevent limb loss (you could get treated and eventually need amputation) - the treatment is mostly aimed to improve quality of life

Question 8

what is chronic limb threatening ischaemia?

Answer 8

• occurs when there is insufficient blood reaching a limb or part of a limb to maintain limb viability
• it may be acute or chronic

Question 9

what does chronic limb threatening ischaemia present as?

Answer 9

excruciating pain present at night & may be relieved for a short while by dependency (position where limb positioned below level of the heart)
- rest pain, ulcers & gangrene can occur

Question 10

what percentage of intermittent claudication turn into chronic limb threatening ischaemia?

Answer 10

4-7% of IC develop into CLTI over 5 years

Question 11

what would you find on clinical examination of peripheral vascular disease?

Answer 11

• cool in peripheries and warmer as you go up leg
• absence of peripheral pulses
• colour change (maybe elevate leg and drain white quickly or put down and get red)
• poor tissue nutrition: hairless, thick nails, shiny skin
• venous guttering
• ulcers
• gangrene

Question 12

what is venous guttering?

Answer 12

condition where the veins have difficulty returning blood from the legs back to the heart, “guttering” refers to the visible appearance of the veins in the legs, where they appear as elongated, tortuous, and bulging channels

Question 13

what investigations would you do if suspected chronic limb threatening ischaemia?

Answer 13

• pulses
• ABPI = ankle brachial pressure index
• duplex (form of ultrasound where you see artery in 2D, can also see flow)
• angiography
  
  • MR angio (must be able to lie flat for 45mins and hard resource)
  • CT angio (good quick but lots of radiation & contrast which affect kidneys)
  • catheter DSA (invasive, complications, not pleasant for patients so try and keep reserve)

Question 14

what’s difficult with pulse finding?

Answer 14

hard to find pulse (poor technique, own pulse, oedema, 10% of adults at least 1 pulse absent)

Question 15

what is ABPI?

Answer 15

ankle-brachial pressure index
- when compare ankle pressure and brachial pressure

ABPI = ankle pressure divided by brachial pressure

Question 16

what is normal ratio of ABPI?

Answer 16

> 1 are normal
<0.9 confirms peripheral arterial disease

0.9-1.2 normal
0.5-0.85 = claudication
0-0.5 = severe

Question 17

what is problem with ABPI?

Answer 17

• in individuals with advanced PAD, particularly those with diabetes, arterial calcification (calcium deposits) can occur, making the arteries rigid and less compressible. This can lead to falsely elevated ABPI values because the blood pressure cuff may not effectively squeeze the stiff arteries, leading to inaccurate measurements of blood pressure in the legs
• doppler signal being “Monophasic” which is when the Doppler signal has only one consistent sound wave. Normally, healthy arteries exhibit a rhythmic, pulsatile flow with a distinctive two-phase (biphasic) sound. In contrast, a monophasic signal lacks this normal variation and may indicate compromised blood flow - this makes it difficult to take blood pressure

Question 18

what affect happens to ABPI when done during exercise?

Answer 18

can drop

Question 19

when is ABPI (Arterial brachial pressure index) test done?

Answer 19

diagnosis of arterial disease

Question 20

when would you do duplex test and what is it?

Answer 20

it’s a non-invasive imaging which involves analysis of flow (combines traditional ultrasound with doppler ultrasound)

• one specific application = Analysis of vein for bypass conduit (surgeons use to evaluate size & suitability of veins in legs & arms to see if can be used as grafts in bypass procedures)

Question 21

what is angiography and what is it used for?

Answer 21

• Gold standard = considered most reliable & accurate method
• provides detailed visualisation of anatomy of blood vessels. it involves the injection of contrast dye into the blood vessels and capturing x-ray images to highlight structures & blood flow in vessels
• Interpreted in conjunction with Duplex

Question 22

what are 3 types of angiogram?

Answer 22

1. magnetic resonance angiography (MRA)
2. CT angiography
3. catheter angiography (digital subtraction angiogram, DSA)

Question 23

what should be assessed for arterial reconstruction?

Answer 23

• Inflow - is there adequate blood getting into affected segment?
• outflow/run off - beyond blockage, do arteries open up?
• conduit = vein or prosthesis
• when to treat? limb salvage vs quality of life
• patients expectation? (high risk surgery, 1 in 20 will have major complication)
• durability of treatment (might not be able to do it)
• open vs endovascular vs combined?
• risks of treatment (high risk)

Question 24

how would you assess where to amputate?

Answer 24

• healing (how well will it heal)
• function (if 90, then more likely to cut higher up)
• tissue loss
• infection

Question 25

what is secondary healing?

Answer 25

healing by secondary intention, is a process of wound healing that occurs when a wound is left open to heal naturally without surgical closure

Question 26

what is primary intention healing?

Answer 26

where surgical intervention, such as stitches or sutures, is used to bring the wound edges together