Arterial Disease Of The Limbs

Question 1

Risk factors for chronic limb ischemia

Answer 1

Male
Age
Smoking
Hypercholesterolemia
Hypotension
Diabetes

Question 2

Less common causes of CLI

Answer 2

Vasculitis, buergers disease

Question 3

Fontaine classification stages

Answer 3

1- asymptomatic, incomplete blood vessel obstruction

2- mild claudication pain
2a walking over 200m
2b walking under 200m

3- rest pain, mostly in feet

4- necrosis and or gangrene of the limb

Question 4

History for CLI (critical limb ischaemia)

Answer 4

Claudication- exercise tolerance, effect of incline, change over time, relieved by rest? Where in the leg, bilateral?

Rest pain- type of pain, relieving factors?

Tissue loss- duration, history of trauma, peripheral sensation

Plus PMH, DH, OH

Question 5

Clinical examination for CLI

Answer 5

Expose both legs and look for ulceration, pallor, hair loss

Feel starting at toes for temperature, capillary refill time, peripheral sensation, pulses

Auscultate with hand held Doppler at dorsalis pedis and posterior tibial pulses

Question 6

Ankle brachial pressure index

Answer 6

Ankle/brachial pressure

1-normal
0.95-0.5- intermittent claudication
0.5-0.3- rest pain
<0.2- gangrene and ulceration

Question 7

Buergers test

Answer 7

Elevate legs look for pallor, angle < 20° is severe ischaemia

Hang feet over bed, if they’re slow to regain colour/ dark red

Question 8

Different types of imagine for CLI

Answer 8

Duplex- dynamic and no contrast BUT not good for abdomen, operator dependant and time consuming

CTA/MRA- detailed and first line for NICE BUT uses contrast and radiation and can overestimate calcification

Digital subtraction angiography

Question 9

Management and treatment of ALD

Answer 9

Same way as CAD

Antiplatelets (reduces risk of needing surgery and all morbidities

Statins (reduce LDL, stops thrombosis and inflammation and plaque rupture)

Target BP of <140/85
Smoking cessation
Diabetic control
Exercise

Open surgery (bypass or endarterectomy- pulling out thrombus)
Endovascular intervention (balloon angioplasty, stent or atherectomy)

Question 10

Surgical bypass

Answer 10

Need inflow, a conduit (vein from legs or arm or synthetic, can use saphenous), outflow

Complications of bleeding, wound infection, pain, scar, DVT, PE, MI, CVA, LRTI, death (2%)

Or damage to nearby vein, artery, nerve, distal emboli, graft failure

Re-intervention up to 40%

5 year patency as low as 45%

Question 11

BASIL trial

Answer 11

Angioplasty is better short term

Surgery is better long term

Question 12

Acute limb ischemia

Answer 12

A medical emergency
30% Embolus or 60% thrombosis in situ

Not DVT or PE

Usually of previously diseased or injured artery

22% post operative mortality

Consider patient wished for palliation or amputation

Question 13

ALI clinical presentation

Answer 13

6Ps
Pain
Pallor
Pulse deficit
Paraesthesia (burning/prickling)
Paralysis
Poikilothermic (cold)

Compare!

Question 14

History for ALI

Answer 14

Cardiac history
Onset and duration
CLI?
RF
Functional status

Question 15

Compartment syndrome

Answer 15

Muscle ischemia irreversible after 6-8hrs

Inflammation, oedema, venous obstruction, tense and tender calf

Rise in creatinine kinase and risk of renal failure

Question 16

Embolectomy

Answer 16

If embolus only it thrombus

Small catheter with balloon to pull it out

Question 17

Diabetic foot disease

Answer 17

25% of diabetic get a foot ulcer
50% get infected
20% need amputation

Microvascular PAD

Question 18

DFU prevention

Answer 18

Always wear good shoes and check and look after

Effective glycaemic control

Question 19

DFU management

Answer 19

Prevention
Diligent wound care
Consider systemic ABx
Investigate for osteomyelitis, gas gangrene, necrotising fasciitis

Larval therapy

Negative pressure wound closure

Skin grafts

Revascularization for very distal (angioplasty, stent, bypass)

Amputation

Question 20

Amputations

Answer 20

Symes at ankle
Transmetatarsal in foot

Above Knee uses 116% energy