Arterial Disease of Limbs: Chronic Limb Ischaemia

Question 1

Pathophysiology?

Answer 1

Atherosclerosis

Less commonly - vasculitsis or buergers disease

Question 2

Risk factors?

Answer 2

Male
Age
Smoking
Hypercholersterolaemia
Hypertension
Diabetes

Question 3

What is stage 1 in the fontaine classifcation?

Answer 3

Asymptomatic

Question 4

What is stage 2?

Answer 4

Mild claudiaction in limbs

Question 5

Stage 2A?

Answer 5

Claudication when walking over 200m

Question 6

Stage 2B?

Answer 6

Claudication when walking under 200m

Question 7

Stage 3?

Answer 7

Rest pain mostly in feet

Question 8

Stage 4

Answer 8

Necrosis and/or gangrene

Question 9

What should you ask in history if patient complains of claudication?

Answer 9

Exercise tolerence
Effect on an incline
Change over time
Is it relived by rest
Where in leg
Type of pain
Is it bilateral

Question 10

What should you ask in history if patient complains of rest pain?

Answer 10

Type of pain and relieving factors

Question 11

What should you ask if its tissue loss?

Answer 11

History of trauma

Peripheral sensation

Question 12

What are we looking for in an examination?

Answer 12

Ulceration
Pallor
Hair loss

Question 13

What are we feeling for in an examination?

Answer 13

Capillary refill times - compare both legs

Temp

Pulses - start at aorta

Peripheral sensation

Question 14

What do we use when auscultating and what are we listening to?

Answer 14

A hand help doppler

Listen to dorsalis pedis and posterior tibial pulses

Question 15

What are some special examinations?

Answer 15

Ankle brachial pressure index

Buergers test

Question 16

What is the ankle brachial pressure index test?

Answer 16

Measures ankle/brachial pressure in mmHg

Question 17

What is the buergers test?

Answer 17

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

Question 18

What causes hyperaemic sunset foot?

Answer 18

Normally only a third of capillaries should open - but in the case of CLI auto-regulation is lost and all open

Question 19

Investigations - two types of imagine used?

Answer 19

Duplex imaging

CT Angiogram/MRA (angiogram) scan

Question 20

Positives and negatives of duplex?

Answer 20

Positives - no radiation/contrast

Negatives - Not good in abdomen
Operator dependent
Time consuming

Question 21

Positives and negatives of CTA/MRA

Answer 21

Positive -

Detailed - allows treatment planning
First line according to NICE

Negatives -

Contrast and radiation
Can overestimate level of calcification
Difficult in low flow states

Question 22

Medical management?

Answer 22

Antiplatelet
Statins

Control risk factors 
BP control 
Better diabetic control
Stop smoking
More exercise

Question 23

Surgical bypass requirements?

Answer 23

Good flow
Outflow
A conduit - vein taken from arm or leg or a synthetic used

Question 24

Complications of a surgical bypass

Answer 24

Bleeding
Wound infection
Pain
Scarring
Damage to nearby VANs
Distal embolism
DVT/PE

Question 25

What is a drastic measure taken to save the patient?

Answer 25

Amputation

Question 26

Patient presents with a severely painful ulcer worse when sleeping/lying - what is it?

Answer 26

Critical limb ischaemia - a severe peripheral artery disease