Arterial disease of the limbs/ critical limb ischaemia

Question 1

5 normal palpable pulses not including radial or brachial

Answer 1

aorta
common femoral artery
popliteal artery 
posterior tibial pulse
dorsalis pedis pulse

Question 2

What is Buerger’s disease

Answer 2

inflammation and thrombosis in small and medium-sized blood vessels, typically in the legs and leading to gangrene. It has been associated with smoking.

Question 3

what is gangrene?

Answer 3

Gangrene is a serious condition where a loss of blood supply causes body tissue to die. It can affect any part of the body but typically starts in the toes, feet, fingers and hands. Gangrene can occur as a result of an injury, infection or a long-term condition that affects blood circulation.

Question 4

risk factors for critical limb ischaemia (8)

Answer 4

Male
Age
Smoking
Hypercholesterolemia
Hypertension
Diabetes
Trauma
Beurgers Disease

Question 5

what is critical limb ischaemia

Answer 5

severe obstruction of the arteries which markedly reduces blood flow to the extremities (hands, feet, and legs) and has progressed to the point of severe pain and even skin ulcers or sores

Question 6

Name, step by step, the progression of lesions from initial to complicated in atherosclerosis

Answer 6

initial lesion
fatty streak
intermediate lesion
atheroma
fibroatheroma
complicated lesion

Question 7

Stages of symptoms in CLI (4)

Answer 7

asymptomatic - incomplete occlusion of blood vessel

mild claudication pain in limb - when walking a distance less than/more than 200 metres

Rest pain - mostly in feet

necrosis and/or gangrene of the limb

Question 8

history taking:- diagnosis of CLI - what things are you looking for? (8)

Answer 8

claudication - exercise tolerance, effect of incline, change over time, relieved by rest? Where in the leg, type of pain?

rest pain - type, relieving factors

tissue loss - duration, history of trauma, peripheral sensation

risk factors
PMH
DH
Occupational history - daily habits
Surgical history

Question 9

What are the 3 visual signs of chronic ischaemia?

Answer 9

Ulceration
pallor - pale appearance
hair loss

Question 10

What are the 2 special examination tests for CLI

Answer 10

Ankle Brachial pressure index - BP should be equal in both places if normal circulation

Buerger’s test - raise leg or hang over the bed

Question 11

Imaging options for CLI (3)

Answer 11

duplex - ultrasound using both doppler and B mode

CTA/MRA

Digital subtraction angiography

Question 12

pros/cons of Duplex

Answer 12

pros:-
dynamic
no radiation/contrast

cons:-
Not good in the abdomen
Operator dependent, time consuming

Question 13

what is duplex scan

Answer 13

A duplex ultrasound combines: Traditional ultrasound: This uses sound waves that bounce off blood vessels to create pictures. Doppler ultrasound: This records sound waves reflecting off moving objects, such as blood, to measure their speed and other aspects of how they flow

Question 14

pros/cons of CTA/MRA

Answer 14

Pros:-
Detailed – allows treatment planning
First line according to NICE

Cons:-
Contrast and radiation
Can overestimate calcification, difficulty in low flow states

Question 15

what is digital subtraction angiography

Answer 15

fluoroscopy technique used in interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue environment.

Question 16

therapy to prevent CLI

Answer 16

antiplatelets

statins

Question 17

what is suggested to control risk factors of CLI

Answer 17

BP control
smoking cessation
diabetic control
exercise

Question 18

what does a surgical bypass require? (3)

Answer 18

inflow

a conduit:-
autologous (from same person) ie a vein from their legs or arm
or synthetic

outflow

Question 19

complications associated with surgical bypass

Answer 19

general - bleeding, wound infection, pain, scar, DVT, PE, MI, Stroke, LRTI, death

technical- damage to nearby vein, artery, nerve, distal emboli, graft failure

Question 20

pathophysiology/ functional changes associated with acute limb ischaemia (5)

Answer 20

Arterial embolus: MI, AF, proximal atherosclerosis (NOT DVT/PE)

Thrombosis: Usually thrombosis of a previously diseased artery.

Trauma

Aortic dissection - Extension of aortic dissection into the iliac and femoral arteries can cause impaired or absent blood flow to the lower limbs

Acute aneurysm thrombosis i.e. popliteal

Question 21

define acute limb ischaemia

Answer 21

a sudden lack of blood flow to a limb. Acute limb ischaemia is caused by embolism or thrombosis

Question 22

6 Ps - clinical signs of peripheral vascular disease/ disease of the limbs

Answer 22

Pain
Pallor
Pulse Deficit
Paraesthesia - tingling sensation
Paresis/Paralysis
Poikilothermia (cold)

Question 23

what are you wanting to find out in a history for CLI? (5)

Answer 23

cardiac history

onset/duration of symptoms

history of chronic limb ischaemia

risk factors for CLI

functional status - ability to perform normal daily activities required to meet basic needs

Question 24

what is compartment syndrome

Answer 24

muscle ischaemia
- pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.

can be acute or chronic

Question 25

presentation of compartment syndrome

Answer 25

tense, tender calf

oedema, inflammation, venous obstruction

risk of renal failure due to myoglobin being present in urine due to tissue destruction

Question 26

management of LI:- if the limb is salvageable then what are your options?

Answer 26

suspicion of embolus only - embolectomy

suspicion of thrombosis in situ (in original place not moved) - mechanical thromboectomy/thrombolysis or open embolectomy +/- bypass

Question 27

management of CLI:- if the limb is not salvageable then what are your options?

Answer 27

palliate - make symptoms/disease less severe without removing limb

or ask patient if they’re willing to have limb amputated. If yes - amputate, if no - palliate

Question 28

irreversible muscle ischaemia can occur in how many hours for acute limb ischaemia?

Answer 28

6-8 hours

Question 29

pathophysiology of diabetic foot disease

Answer 29

microvascular peripheral artery disease

peripheral neuropathy

foot deformity

minor trauma

mechanical imbalance

susceptibility to infection

Question 30

management of diabetic foot ulcers (6)

Answer 30

prevention - better than cure

diligent wound care

infection - consider systemic antibiotics

investigate for osteomyelitis, gas gangrene, necrotising fasciitis

revascularisation - very distal disease - distal bypass or distal crural angioplasty/stent

amputation - high amputation rate

Question 31

other treatment that can be used alongside primary treatment for diabetic foot ulcers

Answer 31

dressings

debridement- larval therapy - maggots onto unhealing wound

negative pressure wound closure

skin grafts

Question 32

venous leg ulcer

Answer 32

A leg ulcer is a long-lasting (chronic) sore that takes more than 4 to 6 weeks to heal. They usually develop on the inside of the leg, just above the ankle