Arterial Disease of the Limbs

Question 1

What are the five pulses you can feel below the waist and where would you find them?

Answer 1

Aorta (above umbilicus, use two hands to feel for pulsation vs expansion)
Common femoral (mid-inguinal point)
Popliteal (popliteal fossa)
Posterior tibial pulse (next to medial malleolus)
Dorsalis pedis - between first two metatarsals of foot.

Question 2

What is the main cause of chronic limb ischaemia?

Answer 2

Atherosclerotic disease of arteries supplying the lower limb.

Question 3

What are some rare causes of CLI?

Answer 3

Vasculitis - swelling of BVs, caused by leukocyte migration.

Burger’s disease - BVs become inflamed and swell and can be blocked with thrombi.

Question 4

What are the risk factors for developing atherosclerotic disease?

Answer 4

Male, age, smoking, hypercholesterolaemia, hypertension and diabetes.

Question 5

How are the symptoms of CLI related to the level of arterial blockage?

Answer 5

The more blocked the arteries the worse the symptoms will be.

Question 6

What is the Fontaine classification?

Answer 6

Used to mark severity of symptoms of CLI.

Question 7

What are the four stages of Fontaine classification?

Answer 7

1 - asymptomatic, incomplete BV obstruction
2 - mild claudication
2A - claudication when walking more than 200m
2B - claudication when walking less than 200m
3 - rest pain, mostly in feet
4 - necrosis, and/or gangrene of limb

Question 8

What kinds of question would you need to ask about claudication?

Answer 8

Exercise tolerance, effect of incline, change over time, relieved by rest? Where in leg, type of pain.

Question 9

What should you ask about rest pain?

Answer 9

Type of pain and relieving factors.

Question 10

What kinds of question would you need to ask about tissue loss?

Answer 10

Duration, history of trauma, peripheral sensation.

Question 11

What signs would you look for in chronic limb ischaemia on the lower limbs?

Answer 11

Ulceration, pallor and hair loss.

Question 12

What things would you examine in the feet?

Answer 12

Capillary refill times, temperature, pulses, peripheral sensation (esp. in diabetics).

Question 13

What is a doppler?

Answer 13

Machine that uses US to determine blood flow through arteries and veins.

Question 14

Where would you use the hand held doppler?

Answer 14

Dorsalis pedis and posterior tibial pulses.

Question 15

What is the ankle brachial pressure index?

Answer 15

ankle pressure/brachial pressure

Can determine clinical status and relates to the symptoms felt by the patient.

Question 16

How do the symptoms worsen in CLI?

Answer 16

Goes from symptom free, to intermittent claudication, rest pain and then to gangrene and ulceration.

Question 17

What special test might you want to carry out if you suspect CLI?

Answer 17

Buerger’s test

Question 18

How do you perform Buerger’s test?

Answer 18

Raise leg and if pallor before 20 degrees elevation then severe ischaemia.

Hang feet over edge of bed, see if slow to regain colour or if go dark red colour (hyperaemic sunset foot).

Question 19

What causes hyperaemic sunset foot?

Answer 19

Because in CLI autregulation is lost and all the capillaries are open (normally a third are open).

Question 20

How should patients with PVD be managed?

Answer 20

The same as those with CHD.

Question 21

What is the best medical therapy in CLI?

Answer 21

Antiplatelet - reduces risk of requiring revascularisation as well as reducing cardiovascular and all-cause mortality.
Statin - inhibits platelet activation and thrombosis, endothelial inflammation activation and plaque rupture.
BP control - target is less than 140/85.
Smoking cessation - excess risk of CV disease diminishes within 4-6 yrs.
Exercise - 150% improvement in walking time.
Diabetic control - 10% of PAD patients are undiagnosed diabetics. Tight glycaemic control prevents microvascular disease.

Question 22

How would you treat mild/moderate CLI?

Answer 22

BMT only.

Question 23

How would you treat moderate/severe CLI?

Answer 23

BMT

Angioplasty/stent, surgical bypass.

Question 24

How would you treat severe/critical CLI?

Answer 24

BMT, angioplasty/stent, endovascular reconstruction, surgical bypass/stent.

Question 25

What four imaging techniques can be used in diagnosis of CLI?

Answer 25

Duplex CTA/MRA Digital subtraction angiogram

Question 26

What are the pros and cons of duplex?

Answer 26

Pros - dynamic and no radiation/contrast Cons - not good in abdomen, operator dependent, time consuming

Question 27

What are the pros and cons of CTA/MRA?

Answer 27

Pros - detailed, allows treatment planning, first line according to NICE Cons - contrast and radiation, can overestimate calcification, difficulty in low flow states

Question 28

What is angiography?

Answer 28

Injecting of dye into arteries for imaging.

Question 29

When would you carry out a surgical bypass?

Answer 29

To try and supply blood to an area that is normally supplied by an occluded artery.

Question 30

What three things does surgical bypass require?

Answer 30

Inflow A conduit (vein from legs, arms, or synthetic PTFE/Dacron) Outflow

Question 31

What are some complications of the bypass surgery?

Answer 31

General - bleeding, wound infection, pain, scar, DVT, PE, MI, CVA, LRTI, death (2%). Technical - damage to nearby vein, artery, nerve, distal emboli, grant failure (stenosis, occlusion).

Question 32

What are some complications of the bypass surgery?

Answer 32

General - bleeding, wound infection, pain, scar, DVT, PE, MI, CVA, LRTI, death (2%). Technical - damage to nearby vein, artery, nerve, distal emboli, graft failure (stenosis, occlusion).

Question 33

What are re-intervention and 5yr patency rates like with surgical bypass procedures?

Answer 33

Re-intervention rate - 18.3-38.8% | 5yr patency rates 45-73%

Question 34

Name some lower limb amputations.

Answer 34

``` Hindquarter Hip disarticulation Above knee Through knee Below knee Symes Transmetatarsals Digit ```

Question 35

What is the motility of BKA and AKAs?

Answer 35

Inside - 80% BKA, 40% AKA | Outside - 65% BKA, 43% AKA

Question 36

How are energy requirements affected by below and above knee amputees?

Answer 36

63% increase in BKA | 117% increase in AKA

Question 37

How does acute limb ischaemia differ from CLI?

Answer 37

???

Question 38

What is an embolus?

Answer 38

A blood clot, air bubble, piece of fatty deposit, or other object which has been carried in the bloodstream to lodge in a vessel and cause an embolism.

Question 39

What is a thrombus?

Answer 39

A blood clot formed in situ within the vascular system of the body impeding flow.

Question 40

What is the pathophysiology of ALI?

Answer 40

Arterial embolus: MI, AF< proximal atherosclerosis (not DVT/PE) Thrombosis - usually thrombosis of a previously diseased artery Trauma Dissection Acute aneurysm thrombosis, i.e. popliteal

Question 41

What are the important things in history taking when you suspect ALI?

Answer 41

``` History of CLI Risk factors for CLI Cardiac history Onset/duration of symptoms Functional status/SH ```

Question 42

What are the 6 Ps in presentation of ALI?

Answer 42

Pain, pallor, perishingly cold, paraesthesia, paralysis, pulseless Always compare to contralateral limb.

Question 43

When do the effects of ACI become irreversible?

Answer 43

After 6-8 hours of onset of symptoms.

Question 44

What is compartment syndrome?

Answer 44

Bleeding/swelling within an enclosed muscle compartment which causes the pressure within a compartment to increase, restricting blood flow which may lead to nerve and muscle damage.

Question 45

What are the results of compartment syndrome?

Answer 45

Muscle ischaemia, inflammation, oedema, venous obstruction.

Question 46

What symptoms are felt in compartment syndrome?

Answer 46

Tense, tender calf.

Question 47

What organ may fail in compartment syndrome?

Answer 47

Kidneys (myoglobulinaemia)

Question 48

What levels may be high in the body during compartment syndrome and why is this?

Answer 48

Creatinine kinase, due to muscle necrosis.

Question 49

How is ALI managed?

Answer 49

ECG, bloods, nil by mouth Analgesia, anticoagulate (heparin - makes blood thinner, any chance of getting blood through it needs to be thinner).

Question 50

If the limb is salvageable and there is suspicion of embolus only what course of action do you take?

Answer 50

Embolectomy

Question 51

If the limb is salvageable and there is suspicion of thrombosis in situ, what two courses of action might you take?

Answer 51

Endovascular mechanical thromboectomy, thrombolysis. or Open embolectomy with or without bypass.

Question 52

If the limb is not salvage what course of action must you take?

Answer 52

If patient is willing for amputation - amputate, if not or amputation not possible then palliate.

Question 53

Embolectomy can be done under what kind of anaesthetic?

Answer 53

GA/LA

Question 54

How many diabetics will develop a foot ulcer in their lifetime?

Answer 54

15%.

Question 55

What are the pathophysiologies of diabetic foot disease?

Answer 55

Microvascular peripheral artery disease Peripheral neuropathy Mechanical imbalance Susceptibility to infection

Question 56

How can diabetics prevent foot disease?

Answer 56

Always wear shoes Check fit of footwear Check pressure points/plantar surface of foot regularly Prompt and regular wound care of skin breaches

Question 57

How can we manage diabetic foot disease?

Answer 57

Prevention Good wound care Tracking infection - consider systemic antibiotics Investigate for osteomyelitis, gas gangrene, necrotising fasciitis.

Question 58

What is a sign of necrotising fasciitis?

Answer 58

Gas in tissues.

Question 59

If foot disease is very distal what can be attempted?

Answer 59

Revascularisation Distal crural angioplasty/stent Distal bypass

Question 60

What the last line of action with diabetic foot disease?

Answer 60

Amputation