Arterial Disease Of Lower Limb

Question 0

Site of stenosis and pain pattern

Answer 0

Superficial femoral or popliteal - calf pain
External iliac/femoral - thigh and calf pain
Aortic bifurcation - buttock, thigh and calf pain
Internal iliac (Leriche syndrome) - bilateral buttock pain and erectile impotence

Question 1

Progression of peripheral arterial occlusive disease symptoms

Answer 1

Intermittent claudication
Shortening claudication distance
Pain when lying flat (loss of gravitational assistance to flow)
Pain at rest when sitting (despite gravitational assistance)

Question 2

Q’s to ask for peripheral arterial diseae

Answer 2

Claudication distance
How long before pain subsides
Effects on ADLs (activity of daily living)
Erectile function
Symptoms of other vascular disease
Family history and previous history
Risk factors: smoking, lipids, diabetes

Question 3

Buerger’s Test

Answer 3

Do straight leg raising slowly, noting point at which ischaemic foot goes pale: check the sole (first sign)
This is the Buerger’s angle: a small angle means more severe ischaemia
Hang legs down: delay in return of colour (second sign)
Followed by reactive cyanosis on affected side third sign)

Question 4

Definition of Acute Limb Ischaemia

Answer 4

Sudden decrease in limb perfusion that causes a threat to limb viability

6 P’s: Pulselessnes, pale, painful, paraesthetic, paralysed, perishingly cold

ABPI <0.1

1 yr mortality rate 20%

Question 5

Definition of Critical Limb Ischaemia

Answer 5

Rest pain requiring opiate analgesia for >2/52
Or
Evidence of tissue necrosis, ulceration or gangrene

ABPI <0.4

1 yr mortality 12% (CVS mortality)

Question 6

Definition of Chronic Limb Ischaemia

Answer 6

Intermittent claudication

ABPI >0.4

1 yr mortality 4% (CVS mortality)

Question 7

Gangrene

Answer 7

Infection plus ischaemia = gangrene
Dead tissue is not painful
Line of demarcation at junction
Common in diabetics
50% of gangrene in diabetics

Question 8

The diabetic foot

Answer 8

Loss of protective sensation
Peripheral neuropathy - loss of ankle jerk plus reduction in light touch and vibration sense leads to injury, corns etc
Dry skin (autonomic neuropathy with loss of sympathetic supply to sweat glands) leads to cracking and infection
Macro and micro vascular disease

Question 9

Arterial ulcers

Answer 9

Small and painful
Over pressure-points: back of heel, plantar aspect of big toe
Punched out margin
At ankle, typically over lateral malleolus
Associated with cold feet, absent pulses and reduced ABPI

Question 10

Ddx for arterial ulcers

Answer 10

Neuropathic ulcers are painless and the foot is warm with reduced sensation
Venous ulcers typically on medial calf or ankle with associated skin changes
10% of ulcers are mixed with venous and arterial components
Compression bandaging contraindicated if arterial component; hence the importance of ABPI prior to txt

Question 11

Management options for Peripheral Arterial Disease

Answer 11

Watchful waiting
Best medical txt (anti-platelet, statins, BP, diabetes)
Endovascular treatments(angioplasty +/- stent)
Surgical reconstruction
Amputation

Aims of intervention: improve CVS risk, reduce lifestyle limiting claudication