29. Arterial Diseases of Limbs Flashcards
Where is the aortic pulse best felt?
- above umbilicus
- use two hands to feel for pulsation vs expansion
Where is the common femoral artery best felt?
- mid-inguinal point
- half way between the anterior superior iliac spine ad the pubic synthesis
Where is the popliteal artery pulse best felt?
-use both hands to feel deep in the popliteal fossa (leg relaxed into your hands)
Where is the posterior tibial pulse best felt?
- half way between medial malleolus (ankle) and the achilles tendon
Where is the dorsalis pedis pulse best felt?
-lateral to the extensor hallucis longus tendon (halfway between first and second toe)
What type of disease is chronic limb ischaemia?
- atherosclerotic disease of the arteries supplying the lower limb
- same disease process as coronary and carotid atherosclerotic disease
- systematic disease (occurs over time)
What is chronic limb ischaemia less commonly known as? (2)
- vasculitis
- Buerger’s disease
What are the main risk factors for chronic limb ischaemia? (6)
- male
- age (older)
- smoking
- hypercholesterolaemia
- hypertension
- diabetes
What are the different sequences/stages of progression in atherosclerosis that lead to chronic limb ischaemia? (6)
- Initial lesion
- fatty streak
- intermediate lesion
- atheroma
- fibroatheroma
- complication lesion
What is initial lesion? (in atheroma formation)
- histologically normal
- macrophage infiltration
- isolated foam cells
- forms from 1st decade
- growth mainly by lipid addition
What is fatty streak? (in atheroma formation)
- mainly intracellular lipid accumulates
- forms from 1st decade
- growth mainly by lipid addition
What is intermediate lesion?( in atheroma formation)
- intracellular lipid accumulation
- small extracellular lipid pools
- forms from 3rd decade
- growth mainly by lipid addition
What is atheroma? (in atheroma formation)
- intracellular lipid accumulation
- core of extracellular lipid
- forms from 3rd decade
- growth mainly by lipid addition
What is fibroatheroma? (in atheroma formation)
- single or multiple lipid cores
- fibrotic/calcific layers (cap)
- forms from 4th decade
- increased smooth muscle and collagen increases
What is a complication lesion? (in atheroma formation)
- surface defect
- haematoma-haemorrhage
- thrombus
- forms from 4th decade
- thrombosis and/or haematoma
From which stage of atheroma formation does the clinical presentation begin at? (symptoms)
from atheroma formation stage (includes fibroatheroma and complicated lesion)
What classification method is used to describe the chronic limb disease staging?
Fontaine Classification
What is Stage 1 Fontaine Classification for chronic limb ischaemia?
- asymptomatic
- incomplete blood vessel obstruction
What is Stage 2 Fontaine Classification for chronic limb ischaemia?
- mild claudication pain in limb
- Stage 2A: claudication when walking a distance of greater than 200m
- Stage 2B: claudication when walking a distance of less than 200m
What is Stage 3 Fontaine Classification for chronic limb ischaemia?
- rest pain mostly in feet
- due to obstruction in arteries (claudication), cramping in feet
What is Stage 4 Fontaine Classification for chronic limb ischaemia?
- necrosis and/or gangrene of the limbs
- tissue starts dying (very bad)
What are the critical features of patient history which should be identified? (3)
- CLAUDICATION: exercise tolerance, effect of incline, change over time, relief at rest, where in leg, type of pain, bilateral, muscle requires more blood due to artery obstruction, leg cramping
- REST PAIN: type of pain, relieving factors, gravity only pushes blood into feet
- TISSUE LOSS: duration, history of trauma, peripheral sensation, reduced sensation
What are the risk factors for chronic limb ischaemia? (4)
- past medical history
- diabetes history
- social history
- occupational history
What are clinical signs on INSPECTION examination indicating chronic limb ischaemia? (3)
- ulceration (tissue loss)
- pallor (unhealthy pale)
- hair loss
(compare both legs)
What 3 types of examination need to be done to detect chronic limb ischaemia?
- inspection
- palpation/feel
- auscultation
What needs to be done on PALPATION examination indicating chronic limb ischaemia? (4)
- capillary refill time
- temperature
- pulses (start at aorta)
- peripheral sensation (particularly in diabetics)
What need to be done on AUSCULTATION examination indicating chronic limb ischaemia?
- dorsalis pedis and posterior tibial pulses checked
to estimate blood flow in these areas
What 2 special tests can also be done to confirm chronic limb ischaemia?
- Ankle Brachial Pressure Index
2. Buerger’s test
What is done for ankle brachial pressure index test?
Division of ankle pressure over brachial pressure which indicates staging of disease
What are 4 stages found following an ankle brachial pressure index test?
- symptoms free (1 or more)
- intermittent claudication (0.95-0.5)
- rest pain (0.5-0.3)
- gangrene and ulceration (<0.2)
What is Buerger’s test?
- elevate legs and check for pallor and Buerger’s angle (<20 degrees) showing severe ischaemia
- hang feet over edge of bed; slow to regain colour or dark red colour (hyperanaemic sunset foot)
- All capillaries in foot open (in normal foot only 1/3 do), autoregulation is lost
What best medical therapy options are there for management of chronic limb ischaemia?
- antiplatelet
- statin
- BP control
- smoking cessation
- exercise
- diabetic control