Arterial Disease of the Limbs Flashcards
What is the pathophysiology of CLI?
Atherosclerosis disease of the arteries supplying the lower limb.
Risk factors - male, age, smoking, hypertension, hypercholesterolemia, and diabetes.
What is the Fontaine Classification of arterial disease?
I - asymptomatic, incomplete obstruction.
II - mild claudication pain.
III - rest pain, mostly in the feet.
IV - necrosis or gangrene.
III and IV = CLI.
What is the diagnosis of CLI?
Claudication - exercise tolerance, the effect of incline, change over time, relieved by rest, location (bilateral), type of pain.
Tissue loss (duration, trauma history, peripheral sensation), risk factors, PMH, DH, occupation (daily habits), surgery.
What is seen on clinical examination of CLI?
Observation - expose both legs. Ulceration, pallor, hair loss (signs of chronic ischaemia).
Palpation - start at the toes, and compare sides (temperature, capillary refill, sensation).
Pulses - start at the aorta.
Auscultation - hand held Doppler (dorsalis pedis and posterior tibial pulses).
What is the Buerger’s Test?
Elevate the legs.
Pallor at <20 degrees = severe ischaemia.
Hang feet over edge of bed - slow to regain colour, dark red colour (hyperaemic sunset foot).
What are the investigations of CLI?
ABPI.
Buerger’s Test.
Duplex.
CTA/MRA - first line.
Digital subtraction angiography.
What are the different values of ABPI?
Asymptomatic - >1.
Intermittent claudication - 0.95-0.5.
Rest pain - 0.5-0.3.
Gangrene and ulceration - <0.2.
What is the management of CLI?
Controlling risk factors - BP <140/85, smoking cessation, diabetes, exercise.
What is the treatment of CLI?
Antiplatelets and statins.
Revascularisation - open surgery or EVAR.
Primary amputation.
What are the risks of a surgical bypass?
General - bleeding, infection, pain, scarring, DVT, PE, MI, CVA, LRTI, death.
Technical - nearby damage, distal emobli, graft failure (stenosis or occlusion).
How should you choose between angioplasty and surgery?
A - preferred for short-term results.
S - for patients with suitable anatomy and a reasonable life expectancy, accepting increased short-term morbidity for long-term durability.
What is the progression and prognosis of CLI?
Progression - 30% amputees, 25% dead, 25% resolved, 20% persists.
Prognosis - 20% mortality in 6 months, 50% 5YS.
What is acute limb ischaemia?
Caused by an arterial embolus (MI, AF, proximal atheroma), thrombosis, trauma, dissection, or acute aneurysm thrombosis.
History - cardiac/CLI history, onset and duration of symptoms, CLI risk factors, functional status.
What are the signs and symptoms of acute limb ischaemia?
Signs - pulse deficit, paraesthesia, paralysis.
Symptoms - pain, pallor, poikilothermia (cold).
What is compartment syndrome?
Muscle ischaemia (irreversible after 6-8hrs).
Inflammation, oedema, venous obstruction.
A tense tender calf.
Rise in creatinine kinase.
Risk of renal failure (myoglobulinaemia).
What is the management of acute limb ischaemia?
If the limb is salvageable - embolectomy, thrombectomy, thrombolysis, open surgery.
If the limb isn’t salvageable - palliate or amputate.
What is the prevalence of diabetic foot disease?
Increasingly common in the Western world.
25% of diabetic patients will develop a foot ulcer in their life. 50% of DFUs become infected; 20% require amputation.
What is the pathophysiology of diabetic foot disease?
Microvascular peripheral artery disease, peripheral neuropathy, mechanical imbalance, foot deformity, minor trauma, susceptibility to infection.
What is the management of diabetic foot disease?
Wear shoes, check fit of footwear.
Avoid minor injuries.
Check pressure points regularly.
Regularly care for wounds and skin breaches.
Effective glycaemic control.
What is the management of pressure ulcers?
Prevention - wound care, systemic abx.
For complicated cases - revascularisation or amputation.
Adjunctive - dressings, debridement (larval therapy), negative pressure wound closure, skin grafts.
