Arterial disease of the Limbs Flashcards
Where should you feel for the aortic pulse?
Above the umbilicus with two hand feel for pulsation vs expansion
Where should you feel for the common femoral aa pulse?
Mid-inguinal point - 1/2 way between anterior superior iliac spine and the pubic symphysis
Where should you feel for he popliteal aa pulse?
Use both hand to feel deep in the popliteal fossa their leg relaxed in your hands
Where should you feel for the posterior tibial pulse?
1/2 way between the medial mallows and the achilles tendon
Where should you feel for the dorsals pedis pulse?
Lateral to the extensor halllucis longs tendon
What are causes for chronic limb ischaemia?
Atherosclerosis of lower limb aa
Less commonly:
Vasculits
Buerger’s disease
What is buerger’s disease?
Inflammation and thrombosis - usually limb aa (can cause gangrene)
What are risk factors for CLI?
Male Age Smoking Hypercholesterolaemia Hypertension Diabetes
What classification is used to stage the CLI?
Fontaine classification (stage 1 - 4)
What symptoms occur in stage 1 of CLI?
Asymptomatic
Incomplete occlusion
What symptoms occur in stage 2 of CLI?
Mild claudication:
2A: when walking > 200m
2B: when walking < 200m
What are symptoms in stage 3 of CLI?
Rest pain, mostly in feet
What symptoms occur in stage 4 of CLI?
Necrosis and/or gangrene of limb
What pattern of symptoms are important to explore in the clinical history of CLI?
Claudication: Exercise tolerance and where in leg
Rest pain: type of pain and relieving factors
Tissue loss: duration, history of trauma and peripheral sensation
What are signs of CLI seen on examination?
Chronic ischaemia:
Ulceration
Pallor
Hair loss
What examination should you carry out in lower limb to test of ischaemia?
Capillary refill
Temp
Pulses
Peripheral sensation
Auscultate: doppler to the dorsals pedis and posterior tibial pulses
What investigations should be carried out for CLI?
Ankle-brachial pressure index
Buegers test
What levels of ABPI indicate CLI (Ankle pressure/brachial)?
Normal: 1
Intermittent claudication: 0.95-0.5
Rest pain: 0.5-0.3
Grangrene: < 0.3 - tissue loss
How do you carry out a buergers test?
Elevate looks and look at pallor:
< 20degrees and limb is pale = severe ischaemia
Hang feet over edge of bed:
Slow to regain colour
Dark red colour (hyperaemic sunset foot) - all capillaries open (usually just 1/3)
What is the best medical therapy (BMT) of CLI?
Antiplatelets Statin BP control: aim < 140/85 Smoking cessation Exercise Diabetic control
What are the use of anti platelets in CLI management?
Reduce risk of requiring revascularisation
What are the use of statins in CLI management?
Inhibits platelet activation and thrombosis
Endothelial inflammation
Plaque rupture
What is the benefit of diabetic control in CLI management?
Tight glycemic control prevent microvascular disease
What is the treatment for stage 2 CLI?
BMT
What is the treatment for stage 3 CLI?
BMT
Angioplastly/stent
Surgical bypass
What is the treatment for stage 4 CLI?
BMT
Angioplasty/stent
Endovascular reconstruction
Surgical bypass
What investigations are carried out for CLI?
CTA/MRA (first line)
Duplex
Digital subtraction angiogram
What are the pros and cons of duplex USS?
Dynamic
No radiation/contrast
BUT
Not good in abdomen
Operator dependent
Time consuming
What are the pros and cons of CTA/MRA?
Detailed - allows treatment planning
BUT
Contrast and radiation
Can over estimate calcification
What is acute limb ischaemia?
Emboli: A thrombus, air bubble, piece of fatty deposit, which has been carried in the blood stream to lodge in a vessel and cause an embolism
Thrombus: a blood clot formed in situ with the vascular system and impeding blood flow
What are causes of acute limb ischaemia?
Arterial embolus (MI, AF, proximal atherosclerosis) Thrombosis Trauma Dissection Acute aneurysm thrombosis (popliteal)
What do you look for in the history of ALI?
History of CLI
Risk factors of CLI
Cardiac history
Onset/duration of symptoms
What are the 6 Ps of the presentation of ALI?
Pain Pallor Perishingly cold Paraesthesia Paralysis Pulseless
Compare to contralateral limb
What can ALI cause?
Compartment syndrome
What is compartment sydrome
Increased pressure within one of the body’s compartments results in insufficient blood supply to tissue within that space
What can increase the pressure in a muscle compartment causing compartment syndrome?
Muscle ischaemia
Inflammation (draws in fluid -> oedema)
Oedema
Venous obstruction (blood builds up)
What are the symptoms and signs of compartment syndrome?
Tense, tender calf
Rise in creatinine kinase
Risk of renal failure (myoglobulinaemia)
What investigations should be carried out for ALI?
ECG
Bloods
Nil by mouth
What is the initial management of ALI?
Analgesia
Anticoagulate
What are the management options for ALI with salvageable limb?
If embolus: embolectomy
If thrombus in situ: thrombolectomy/ thrombolysis OR open embolectomy +/- bypass
What are the management options for ALI with a non-salvageable limb?
Palliate
Fit for surgery: Amputate
What is diabetic foot disease?
Uncontrolled diabetes causing the development of neuropathy and peripheral arterial disease
Also causes:
Mechanical imbalance
Susceptibility to infection
Why is prevention key in diabetic foot disease?
Limited options for surgical intervention
Footcare
Glycaemic control
How can a diabetic improve footcare?
Always wear shoes
Check shoes fit
Check pressure points/plantar surface of fat regularly
Prompt and regular wound care of skin breaches
What is the management for diabetic foot disease?
Prevention Good wound care Tracking infection: systemic antibiotics Investigate for: Osteomyelitis Gas gangrene Necrotising fasciitis
What are surgical options to manage diabetic foot disease?
Revascularisation:
Angioplasty/stent if distal
Distal bypass
Amputation
