Arterial disease of the limbs

Question 1

Risk factors of atherosclerotic disease of arteries supplying lower limb

Answer 1

• male
• age
• smoking
• hypercholesterolemia
• hypertension
• diabetes

Question 2

Describt the fontaine classification

Answer 2

Stage I: Asymptomatic, incomplete blood vessel obstruction

Stage II: Mild claudication pain in limb

Stage IIA: Claudication when walking a distance of greater than 200 meters

Stage IIB: Claudication when walking a distance of less than 200 meters

Stage III: Rest pain, mostly in the feet

Stage IV: Necrosis and/or gangrene of the limb

Question 3

What is claudication?

Answer 3

-cramping of leg during excercise

Question 4

State clinical signs of chronic ischaemia of leg

Answer 4

1

• ulceration
• pallor
• hair loss

2
FEEL
-temperature
-capillary refill tie
-peripheral sensation
-pulses ( start at aorta)
AUSCULTATE- hand held doppler ( dorsalis pedis and posterior tibial pulses)

Question 5

Special examination tests

Answer 5

1. Ankle brachial pressure index

2. Buerger’s test

Question 6

Describe buerger’s test

Answer 6

Elevate the legs

• pallor
• buerger’s angle ( <20 degrees severe ischaemia)

Hang feet over edge of bed

• slow to regain color
• dark red color (hyperaemic sunset foot)

Question 7

Investigations

Answer 7

Duplex

• no radiation/contrast but not good in abdomen
• operator dependent, time cons

CTA/MRA

• detailed
• contrast + radiation
• overestimates calcification

Digital subtraction angiography

Question 8

Medical treatment

Answer 8

Combination of:
anti platelet; reduces risk requiring revascularization
statin; inhibits platelet activation + thrombosis, endothelial + inflammation activation, plaque rupture

Question 9

What is revascularization

Answer 9

Open surgery

• bypass and/or
• endarterectomy ) open artery, clean plaque to prevent narrpwing

Endovascular intervention

• balloon angioplasty
• stent placement
• artherctomy

Question 10

What is surgical bypass?

Answer 10

procedure that requires inflow + a conduit: autologus(vein from leg/arm), synthetic ( PTFE/Dracon) + outflow

Question 11

Surgical complications of surgical bypass

Answer 11

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

Question 12

Types of stent

Answer 12

• balloon expandable
• self expanding
• wallstent
• covered stent

Question 13

Pathphysiology of limb ischaemia

Answer 13

• arterial embolus: MI, AF, proximal atherosclerosis ( NOT DVT/PE)
• thrombosis
• trauma
• dissection
• acute anuerysm thrombosis(eg popliteal)

Question 14

Clinical presentations of limb ischaemia (comp.syndrome)

Answer 14

6 P’s

• pain
• pallor
• pulse deficit
• paraesthesia
• paresis/paralysis
• poikilothermia

Question 15

What is compartment syndrome? What can it lead to?

Answer 15

painful condition that occurs –when pressure within the muscles builds to dangerous levels.

• muscle ischaemia ( irreversible after 6-8 hours)
• inflammation, oedema, venous obstruction
• tense, tender calf
• rise in creatine kinase + risk of renal failure ( myoglobinaemia)

Question 16

Treatment of limb ischaemia

Answer 16

-palliation, amputation, embolectomy?

Question 17

Pathphysigy of diabetic foot disease(ulcer)

Answer 17

• microvascular peripheral artery disease
• peripheral neuropathy
• mechanical imbalance
• foot deformity
• minor trauma
• predisposes infection

Question 18

Preventation of DFU

Answer 18

• wear shoes to avoid minor injuries
• check pressure points/plantar surface of foot regularly
• wound care
• glycaemic control