Acute + chronic limb ischaemia Flashcards
What is peripheral arterial disease?
narrowing or occlusion of the peripheral arteries, affecting blood supply to the lower limbs
Modifiable risk factors for peripheral arterial disease
smoking
diabetes
hypertension
hypercholesterolaemia
hyperhomocysteinaemia
CRP
Describe the Fontaine classification of peripheral arterial disease
1 = asymptomatic
2a = mild claudication
2b = moderate to severe (short distance) claudication
3 = ischaemic rest pain
4 = ulceration or gangrene
Symptoms of peripheral arterial disease
asymptomatic
intermittent claudication
exercise-induced muscle pain - calf, buttocks, thigh
worse walking uphill or hurrying
relieved by rest <10 mins
Describe sites of intermittent claudication and the associated arteries
Buttock + hip = aortoiliac disease
Thigh = aortoiliac or common femoral artery
Upper 2/3 of calf = superficial femoral artery
Lower 1/3 of calf = popliteal artery
Foot claudication = tibial or peroneal artery
What is Leriche syndrome?
severe atherosclerosis affecting the distal abdominal aorta, iliac arteries, and femoro-popliteal vessels
triad = claudication, absent femoral pulses, erectile dysfunction
Differential diagnoses for peripheral arterial disease
Vascular = aneurysm, limb trauma, radiation exposure, vasculitis, popliteal entrapment syndrome, chronic venous disease
Neurological pain = neurospinal (eg. disc disease, spinal stenosis tumour) or neuropathic (eg. DM, alcohol abuse)
Musculoskeletal = pain derived from bones, joints, ligaments, tendons and fascial elements of lower extremity
What are 3 symptoms of chronic limb threatening ischaemia? (CLTI)
Ischaemic rest pain - severe pain at rest due to inadequate oxygen perfusion
Ischaemic ulcer - formed at sites of increased focal pressure (malleoli, tips of toes, metatarsal heads, heels - usually dry + punctuate)
Gangrene - dry or wet
Describe dry gangrene
common in diabetic patients
develops when there is impaired blood flow to an area
tissue dries up - brown to purplish-blue to black in colour
infection not typically present
can lead to wet gangrene
Describe wet gangrene
liquefactive necrosis due to infection
tissue swells + blisters
wet because of pus
infection can quickly spread throughout body
Wet gangrene treatment
High dose IV abx
revascularisation, debridement +/- amputation
List 4 vascular investigations
duplex ultrasound
CT angiography
magnetic resonance angiography
contrast angiography
Management: asymptomatic patients of mild claudication (peripheral arterial disease)
lifestyle modification:
- smoking cessation
- exercise
- diet control
pharmacological:
- risk factor modification (control BP, diabetes, dyslipidaemias)
- antiplatelet therapy
- cholesterol lowering medication
Management: short distance claudication (peripheral arterial disease)
lifestyle modification:
- smoking cessation
- exercise
- diet control
pharmacological:
- risk factor modification (control BP, diabetes, dyslipidaemias)
- antiplatelet therapy
- cholesterol lowering medication
- Naftidrofuryl/Cilostazol
endovascular:
- angioplasty +/- stent placement
surgical:
- endarterectomy
- peripheral bypass graft (autologous vein/prosthetic)
What is angioplasty?
pressure controlled balloon inflation to fracture arterial plaque and remodel the artery
most effective for short focal stenoses without heavy calcification
