Arterial disease of the Limbs

Question 1

Where should you feel for the aortic pulse?

Answer 1

Above the umbilicus with two hand feel for pulsation vs expansion

Question 2

Where should you feel for the common femoral aa pulse?

Answer 2

Mid-inguinal point - 1/2 way between anterior superior iliac spine and the pubic symphysis

Question 3

Where should you feel for he popliteal aa pulse?

Answer 3

Use both hand to feel deep in the popliteal fossa their leg relaxed in your hands

Question 4

Where should you feel for the posterior tibial pulse?

Answer 4

1/2 way between the medial mallows and the achilles tendon

Question 5

Where should you feel for the dorsals pedis pulse?

Answer 5

Lateral to the extensor halllucis longs tendon

Question 6

What are causes for chronic limb ischaemia?

Answer 6

Atherosclerosis of lower limb aa

Less commonly:
Vasculits
Buerger’s disease

Question 7

What is buerger’s disease?

Answer 7

Inflammation and thrombosis - usually limb aa (can cause gangrene)

Question 8

What are risk factors for CLI?

Answer 8

Male 
Age
Smoking 
Hypercholesterolaemia
Hypertension 
Diabetes

Question 9

What classification is used to stage the CLI?

Answer 9

Fontaine classification (stage 1 - 4)

Question 10

What symptoms occur in stage 1 of CLI?

Answer 10

Asymptomatic

Incomplete occlusion

Question 11

What symptoms occur in stage 2 of CLI?

Answer 11

Mild claudication:
2A: when walking > 200m
2B: when walking < 200m

Question 12

What are symptoms in stage 3 of CLI?

Answer 12

Rest pain, mostly in feet

Question 13

What symptoms occur in stage 4 of CLI?

Answer 13

Necrosis and/or gangrene of limb

Question 14

What pattern of symptoms are important to explore in the clinical history of CLI?

Answer 14

Claudication: Exercise tolerance and where in leg
Rest pain: type of pain and relieving factors
Tissue loss: duration, history of trauma and peripheral sensation

Question 15

What are signs of CLI seen on examination?

Answer 15

Chronic ischaemia:
Ulceration
Pallor
Hair loss

Question 16

What examination should you carry out in lower limb to test of ischaemia?

Answer 16

Capillary refill
Temp
Pulses
Peripheral sensation

Auscultate: doppler to the dorsals pedis and posterior tibial pulses

Question 17

What investigations should be carried out for CLI?

Answer 17

Ankle-brachial pressure index

Buegers test

Question 18

What levels of ABPI indicate CLI (Ankle pressure/brachial)?

Answer 18

Normal: 1
Intermittent claudication: 0.95-0.5
Rest pain: 0.5-0.3
Grangrene: < 0.3 - tissue loss

Question 19

How do you carry out a buergers test?

Answer 19

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)

Question 20

What is the best medical therapy (BMT) of CLI?

Answer 20

Antiplatelets
Statin 
BP control: aim < 140/85
Smoking cessation 
Exercise 
Diabetic control

Question 21

What are the use of anti platelets in CLI management?

Answer 21

Reduce risk of requiring revascularisation

Question 22

What are the use of statins in CLI management?

Answer 22

Inhibits platelet activation and thrombosis
Endothelial inflammation
Plaque rupture

Question 23

What is the benefit of diabetic control in CLI management?

Answer 23

Tight glycemic control prevent microvascular disease

Question 24

What is the treatment for stage 2 CLI?

Answer 24

BMT

Question 25

What is the treatment for stage 3 CLI?

Answer 25

BMT Angioplastly/stent Surgical bypass

Question 26

What is the treatment for stage 4 CLI?

Answer 26

BMT Angioplasty/stent Endovascular reconstruction Surgical bypass

Question 27

What investigations are carried out for CLI?

Answer 27

CTA/MRA (first line) Duplex Digital subtraction angiogram

Question 28

What are the pros and cons of duplex USS?

Answer 28

Dynamic No radiation/contrast BUT Not good in abdomen Operator dependent Time consuming

Question 29

What are the pros and cons of CTA/MRA?

Answer 29

Detailed - allows treatment planning BUT Contrast and radiation Can over estimate calcification

Question 30

What is acute limb ischaemia?

Answer 30

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

Question 31

What are causes of acute limb ischaemia?

Answer 31

``` Arterial embolus (MI, AF, proximal atherosclerosis) Thrombosis Trauma Dissection Acute aneurysm thrombosis (popliteal) ```

Question 32

What do you look for in the history of ALI?

Answer 32

History of CLI Risk factors of CLI Cardiac history Onset/duration of symptoms

Question 33

What are the 6 Ps of the presentation of ALI?

Answer 33

``` Pain Pallor Perishingly cold Paraesthesia Paralysis Pulseless ``` Compare to contralateral limb

Question 34

What can ALI cause?

Answer 34

Compartment syndrome

Question 35

What is compartment sydrome

Answer 35

Increased pressure within one of the body's compartments results in insufficient blood supply to tissue within that space

Question 36

What can increase the pressure in a muscle compartment causing compartment syndrome?

Answer 36

Muscle ischaemia Inflammation (draws in fluid -> oedema) Oedema Venous obstruction (blood builds up)

Question 37

What are the symptoms and signs of compartment syndrome?

Answer 37

Tense, tender calf Rise in creatinine kinase Risk of renal failure (myoglobulinaemia)

Question 38

What investigations should be carried out for ALI?

Answer 38

ECG Bloods Nil by mouth

Question 39

What is the initial management of ALI?

Answer 39

Analgesia | Anticoagulate

Question 40

What are the management options for ALI with salvageable limb?

Answer 40

If embolus: embolectomy If thrombus in situ: thrombolectomy/ thrombolysis OR open embolectomy +/- bypass

Question 41

What are the management options for ALI with a non-salvageable limb?

Answer 41

Palliate | Fit for surgery: Amputate

Question 42

What is diabetic foot disease?

Answer 42

Uncontrolled diabetes causing the development of neuropathy and peripheral arterial disease Also causes: Mechanical imbalance Susceptibility to infection

Question 43

Why is prevention key in diabetic foot disease?

Answer 43

Limited options for surgical intervention Footcare Glycaemic control

Question 44

How can a diabetic improve footcare?

Answer 44

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

Question 45

What is the management for diabetic foot disease?

Answer 45

``` Prevention Good wound care Tracking infection: systemic antibiotics Investigate for: Osteomyelitis Gas gangrene Necrotising fasciitis ```

Question 46

What are surgical options to manage diabetic foot disease?

Answer 46

Revascularisation: Angioplasty/stent if distal Distal bypass Amputation