Arterial Disease of the Limbs Flashcards
What are the 5 pulses in this lecture?
Aorta Common femoral artery Popliteal artery Posterior tibial pulse Dorsalis pedis pulse
Where and how is the pulse of the aorta palpated?
Above the umbilicus
Use two hands to fell for the pulsation compared to the expansion
Where and how is the pulse of the common femoral artery palpated?
Mid-inguinal point, half way between the anterior superior iliac spine and the pubic symphysis
Where and how is the pulse of the popliteal artery palpated?
Use both hands to feel deep in the popliteal fossa
Where and how is the pulse of the posterior tibial pulse palpated?
Half way between the medial malleolus and the achilles tendon
Where and how is the pulse of the dorsals pedis pulse palpated?
Lateral to the extensor hallucis longs tendon
What causes critical limb ischaemia?
Atherosclerotic disease of the arteries supplying the lower limbs
Vasculitis
Burger’s disease
What are the risk factors for CLI?
Male Age Smoking Hypercholesterolaemia Hypertension Diabetes
What symptoms are associated with stage 1 CLI?
Asymptomatic, incomplete vessel obstruction
What symptoms are associated with stage 2 CLI?
Mild claudication
A- claudication when walking a distance greater than 200 meters
B - claudication when walking a distance less than 200 meters
What is claudication?
Pain in the calves that is usually bilateral
What symptoms are associated with stage 3 CLI?
Pain at rest, mostly in the feet
What symptoms are associated with stage 4 CLI?
Necrosis and/or gangrene of the limbs
What are you looking for in the history and examination to diagnose CLI?
Claudication
Rest pain
Tissue loss
Examine the legs for:
Ulceration
Pallor
Hair loss
What should be done during the examination?
Capillary refill times Temp Pulses starting at the aorta Peripheral sensation Auscultate, using a hand held doppler, the dorsalis pedis and posterior tibial pulses Ankle brachial pressure index Buerger's test
How is the ankle brachial pressure index calculated?
Ankle pressure decided by brachial pressure in mmHg
What is the scaling system for the ankle brachial pressure index?
1 or more - symptom free
0.5-0.95 - intermittent claudication
0.3-0.5 - rest pain
<0.2 - gangrene and ulceration
How is the Buerger’s test carried out?
Lift up leg of patient lying flat and observe for colour change
If there is a colour change before the leg is lifted to 20 degrees then there is severe ischamea
Let the leg down and ask the patient to sit on the side of the bed and observe how long it takes for the leg to return to normal colour
How is peripheral vascular disease managed?
Antiplatelets Statins Blood pressure control to get to 140/85 or less Aim for 150% improvement in walking time Diabetic control
What can be done to treat severe CLI?
Angioplasty/stent
Surgical bypass
BMT
What can be done to treat critical CLI?
BMT
Angioplasty/stent
Endovascular reconstruction
Surgical bypass
What imaging is used to investigate for CLI?
Duplex
CTA/MRA
Digital subtraction angiogram
What does surgical bypass require?
Inflow
Outflow
A conduit - autologous or synthetic
What are the risks of surgical bypass?
Bleeding Wound infection Pain Scar Deep vein thrombosis Pulmonary embolism MI CVA/stroke Lower respiratory tract infection Death Damage to nearby vein, artery or nerve Distal emboli Graft failure
What is acute limb ischaemia?
It is when there is a sudden lack of blood flow to a limb
What causes acute limb ischaemia?
Arterial emboli Thrombosis Trauma Dissection Acute aneurysm thrombosis
What Is the presentation of acute limb ischaemia?
Pain Pallor Perishingly cold Paraesthesia Paralysis Pulseless
What is the management of ALI if the limb is salvageable and it is caused only by an embolus?
Embolectomy
What is the management of ALI if the limb is salvageable and a thrombus in situ is suspected?
Mechanical thrombectomy/thrombolysis
Open embolectomy and possibly surgical bypass
What is the management of ALI if the limb is not salvageable?
If it can be amputated amputate, if not then palliate
In ALI what happens after 6-8 hours?
Irreversible muscle ischaemia
What is compartment syndrome?
Increased pressure in one compartment of the body which can cause muscle ischaemia, inflammation, oedema and venous obstruction
How does compartment syndrome affect a person?
Makes the compartment tense and tender
What is there an increased level of in compartment syndrome?
Kinase
What is there a risk of with compartment syndrome?
Renal failure
What is diabetic foot disease?
A foot that exhibits any pathology due to diabetes
What is the pathophysiology of diabetic foot disease?
Microvascular peripheral artery disease
Peripheral neuropathy
Mechanical imbalance
Susceptibility to infection
What can be done in terms of foot care?
Always wear shoes
Check fit of footwear
Check feet regularly
Prompt and regular wound care of skin breaches
How is diabetic foot disease managed?
Good wound care
Tracking infection - possibly systemic antibiotics
Investigate for osteomyelitis, gas gangrene and necrotising fasciitis
What is the surgical treatment of diabetic foot disease?
Revascularisation
Amputation
What are the results of diabetic foot disease?
Infection
Diabetic foot ulcers
Neuropathic osteoarthropathy
