Arterial Disease of Limbs: Chronic Limb Ischaemia Flashcards
Pathophysiology?
Atherosclerosis
Less commonly - vasculitsis or buergers disease
Risk factors?
Male Age Smoking Hypercholersterolaemia Hypertension Diabetes
What is stage 1 in the fontaine classifcation?
Asymptomatic
What is stage 2?
Mild claudiaction in limbs
Stage 2A?
Claudication when walking over 200m
Stage 2B?
Claudication when walking under 200m
Stage 3?
Rest pain mostly in feet
Stage 4
Necrosis and/or gangrene
What should you ask in history if patient complains of claudication?
Exercise tolerence Effect on an incline Change over time Is it relived by rest Where in leg Type of pain Is it bilateral
What should you ask in history if patient complains of rest pain?
Type of pain and relieving factors
What should you ask if its tissue loss?
History of trauma
Peripheral sensation
What are we looking for in an examination?
Ulceration
Pallor
Hair loss
What are we feeling for in an examination?
Capillary refill times - compare both legs
Temp
Pulses - start at aorta
Peripheral sensation
What do we use when auscultating and what are we listening to?
A hand help doppler
Listen to dorsalis pedis and posterior tibial pulses
What are some special examinations?
Ankle brachial pressure index
Buergers test
What is the ankle brachial pressure index test?
Measures ankle/brachial pressure in mmHg
What is the buergers test?
A test of arterial sufficiency
Elevate legs and look at the angle at which legs go pale - if <20 degrees it shows severe ischaemia
Then hang legs over side of bed and observe speed at which colour returns
Should be slow and end in a dark red colour known as hyperaemic sunset foot
What causes hyperaemic sunset foot?
Normally only a third of capillaries should open - but in the case of CLI auto-regulation is lost and all open
Investigations - two types of imagine used?
Duplex imaging
CT Angiogram/MRA (angiogram) scan
Positives and negatives of duplex?
Positives - no radiation/contrast
Negatives - Not good in abdomen
Operator dependent
Time consuming
Positives and negatives of CTA/MRA
Positive -
Detailed - allows treatment planning
First line according to NICE
Negatives -
Contrast and radiation
Can overestimate level of calcification
Difficult in low flow states
Medical management?
Antiplatelet
Statins
Control risk factors BP control Better diabetic control Stop smoking More exercise
Surgical bypass requirements?
Good flow
Outflow
A conduit - vein taken from arm or leg or a synthetic used
Complications of a surgical bypass
Bleeding Wound infection Pain Scarring Damage to nearby VANs Distal embolism DVT/PE
What is a drastic measure taken to save the patient?
Amputation
Patient presents with a severely painful ulcer worse when sleeping/lying - what is it?
Critical limb ischaemia - a severe peripheral artery disease
