Arterial Disease of the Limbs - Presentation, Investigation & Therapy Flashcards
What are examples of arterial diseases of the limbs?
Peripheral artery disease
Acute limb ischaemia
Diabetic foot disease
What is A?
Aorta
What is B?
Illiac arteries
What is C?
Common femoral artery
What is D?
Profunda femoris
What is E?
Superficial femoral artery
What is F?
Poplital artery
What is G?
Anterior tibial artery
What is H?
Dorsalis pedis
What is I?
Posterior tibial artery
What is J?
Peroneal artery
What are normal palpable pulses of the lower limbs?
Aorta
Common femoral artery
Popliteal artery
Posterior tibial pulse
Dorsalis pedis pulse
Where is the aorta palpable?
Where is the common femoral artery palpable?
Mid-inguinal point, half way between the anterior superior iliac spine and the pubic symphysis
Where is the popliteal artery palpable?
Use both hands to feel dleep in the popliteal fossa, leg relaxed into your hands
Where is the posterior tibial pulse palpable?
Half-way between the medial malleolus and the achilles tendon
Where is the dorsalis pedis pulse palpable?
Lateral to the extensor hallucis longus tendon
What does CLI stand for?
Critical limb ischaemia
What is critical limb ischaemia?
Advanced stage of peripheral artery diseases
What is the pathophysiology of critical limb ischaemia?
Atherosclerotic diseases of the arteries to the lower limbs
Vasculitis
Buerger’s disease
What is vasculitis?
Disorders that destroy blood vessels by inflammation
What are disorders that destroy blood vessels by inflammation called?
Vasculitis
What is Buerger’s disease?
Inflammation and thrombosis in small and medium sized blood vessels, typically in the legs
What is inflammation and thrombosis in small and medium sized blood vessels, typically in the legs called?
Buerger’s disease
What do critical limb diseases use the same process as?
Coronary and carotid atherosclerotic disease
What are some risk factors for critical limb ischaemia?
Male
Age
Smoking
Hypercholesterolaemia
Hypertension
Diabetes
Are males or females more at risk from critical limb disease?
Males
What classification is used to classify the stages of peripheral artery disease?
Fontaine classification
What are the different classes of peripheral artery disease?
Stage I
Stage II
Stage III
Stage IV
What is stage I peripheral artery disease?
Asymptomatic, incomplete blood vessel obstruction
What is stage II peripheral artery disease?
Mild claudication pain in the limb
What is stage III peripheral artery disease?
Rest pain, mostly in the feet
What is stage IV peripheral artery disease?
Necrosis and/or gangrene of the limb
Which stage of peripheral artery disease has a A and B?
As well as stage II there is,
Stage IIA
Stage IIB
What is stage IIA peripheral artery disease?
Claudication when walking a distance greater than 200m
What is stage IIB peripheral arterial disease?
Claudication when walking a distance less than 200m
What stages of peripheral artery disease are considered to be criticial limb ischaemia?
Stages III and IV
What is claudication?
A condition in which cramping pain in the leg is induced by exercise. typically caused by obstruction of the artery
What is a condition in which cramping of the leg is induced by exercise, typically caused by obstruction of the arteries?
Claudication
What are common findings in the history for peripheral artery disease?
Claudication
Tissue loss
Rest pain
What questions should be asked for claudication in a history?
Exercise tolerance
Effect of incline
Change over time
Relieved by rest?
Where in the leg
Type of pain
Bilateral?
What questions should be asked for rest pain in the history of peripheral vascular disease?
Type of pain
Relieving factors
What questions should be asked fpr tissue loss in the history?
Duration
History of trauma
Peripheral sensation
What are clinical examination findings for peripheral arterial disease?
Ulceration
Pallor
Hair loss
Temperature
Capillary refill time
Peripheral sensatio
Pulses
Dorsalis pedis and posterior tibial pulses listened to
What are some special examination findings for peripheral arterial disease?
Ankle brachial pressure index
Elevate legs and look for pallor and Buerger’s angle
Hang feet over edge of bed and look for time to regain colour
What is the ankle brachial pressure index?
Ratio of the blood pressure at the ankles to the blood pressure in the upper arm
What is pallor?
An unhealthy pale appearance
What is an unhealthy pale appearance?
Pallor
What is Buerger’s angle?
Angle which the leg has to be raised before it becomes pale whilst lying down
What is the angle at which the leg has to be raised before it becomes pale whilst lying down?
Buerger’s angle
What Buerger’s angle is severe ischaemia?
Less than 20 degrees
What does ABPI stand for?
Ankle brachial pressure index
What imaging investigations are done for peripheral arterial disease?
Duplex
CTA/MRA
Digital subtraction angiography
What is duplex imaging?
Ultrasound captures images of arteries
What are advantages of duplex imaging?
Dynamic
No radiation/contrast
What are disadvantages of duplex imaging?
Not good in the abdomen
Operator dependant
Time consuming
What are the advantages of CTA/MRA?
Detailed
First line according to NICE
What are the disadvantages of CTA/MRA?
Contrast and radiation
Can overestimate calcification
What is digital subtraction angiography?
Fluoroscopy technique used in interventional radiology to clearly visualise blood vessels in a body or dense soft tissue environment
What is imagine using fluoroscopy technique used in interventional radiology to clearly visualise blood vessels in a body or dense soft tissue environment?
Digital subtraction angiography
What is the management of peripheral artery disease?
Medical therapy
Risk factor control
Exercise
Revascularisation
What is peripheral arterial disease managed in the same way as?
Established coronary artery disease
Why is peripheral arterial disease managed in the same way as established coronary artery disease?
People with peripheral arterial disease are at high risk of developing coronary artery disease
What is the best medical therapy for peripheral vascular disease?
Combination of antiplatelets and statins
How to antiplatelets help with peripheral arterial disease?
Reduces risk of requiring revascularisation as well as cardiovascular and all-cause mortality
How do statins help with treating peripheral arterial disease?
Inhibits platelet activation and thrombosis, endothelial and inflammation activation, plaque rupture
What management is used for risk factor control for peripheral arterial disease?
Blood pressure target of <140/85
Smoking cessation
Diabetic control
What are 2 different categories of revascularisation?
Open surgery
Endovascular intervention
What are examples of open surgery procedures for revascularisation?
Bypass
Endarterectomy
What are examples of endovascular intervention procedures for revascularisation?
Balloon angioplasty
Stent placement
Atherectomy
What does a surgical bypass require?
Inflow
A conduit
Outflow
What are risks of complications for surgical bypass?
Bleeding
Wound infection
Pain
Scar
Deep vein thrombosis
Myocardial infarction
Pulmonary embolism
Cerebrovascular accident
Lower respiratory tract infection
Death
What is the re-intervention rate of surgical bypass?
10-39%
What is the 5 year patency rate of surgical bypass?
45-75%
What is the cost of using surgery for revascularisation?
Greater short term morbidity as a price for greater long term durability
What is angioplasty?
A non-invasive procedure to widen narrowed arteries
What is acute limb ischaemia?
Occurs when there is a lack of blood flow to a limb
What is the pathophysiology of acute limb ischaemia?
Arterial embolus
Thrombosis
Trauma
Dissection
Acute aneurysm thrombosis
What is an embolus?
A blood clot, air bubble, piece of fatty deposit or other object which has been carried in the bloodstream to lodge in a vessel and cause an obstruction
What is a blood clot, air bubble, piece of fatty deposit or other object which has been carried in the bloodstream to lodge in a vessel and cause an obstruction called?
Embolus
What is a thrombus?
A blood clot formed in sutu within the vascular system of the body and impeding blood flow
What is a blood clot formed in sutu within the vascular system of the body and impeding blood flow called?
Thrombus
What is the clinical presentation of acute limb ischaemia?
Pain
Pallor
Pulse deficit
Paraesthesia
Paresis/paralysis
Poikilothermia
What is poikilothermia?
The inability of someone to regulate their body temperature
What is the inability of someone to regulate their body temperature called?
Poikilothermia
What is the usual history for acute limb ischaemia?
Cardiac history
Onset/duration of symptoms
Histroy of chronic limb ischaemia
Risk factors for critical limb ischaemia
Functional status
What syndrome can cause acute limb ischaemia?
Compartment syndrome
What is compartment limb syndrome?
Painful condition that occurs when pressure within the muscles builds up to dangerous levels, which can decrease blood flow
What is a painful condition that occurs when pressure within the muscles builds up to dangerous levels which can decrease blood flow?
Compartment syndrome
How does compartment syndrome present?
Muscle ischaemia (irreversible after 6-8 hours)
Inflammation, oedema and venous obstruction
Tense, tender calf
Rise in creatine kinase
Risk of renal failure (myoglobulinaemia)
What is myoglobulinaemia?
Presence of myoglobin in the urine
What is presence of myoglobin in the urine called?
Myoglobulinaemia
When is muscle ischaemia due to compartment syndrome irreversible?
After 6-8 hours
What are the different categories of acute limb ischaemia?
I (viable)
II (threatened)
A (marginally)
B (immediately)
III (irreversible)
What is stage I acute limb ischaemia?
Not imminently threatened
What is stage IIA acute limb ischaemia?
Salvageable if promtly treated
What is stage IIB acute limb ischaemia?
Salvageable with immediate revascularisation
What is stage III acute limb ischaemia?
Major tissue loss or permanent nerve damage inevitable
What is required if the limb due to acute limb ischaemia is not salvageable?
Amputation or palliation
What is diabetic foot disease?
Foot affected by ulceration associated with neuropathy and/or peripheral artery disease of the lower limb in a patient with diabetes
What is foot affected by ulceration associated with neuropathy and/or peripheral artery disease of the lower limb in a patient with diabetes called?
Diabetic foot disease
What percentage of diabetic patients will develop a foot ulcer in their lifetime?
25%
What percentage of diabetic foot ulcers become infected and what percentage requires amputation?
50% become infected
20% require amputation
What is the pathophysiology of diabetic foot disease?
Microvascular peripheral artery disease
Peripheral meuropathy
Mechanical imbalance
Foot deformity
Minor trauma
Susceptibility to infection
What is some foot care for diabetic foot ulcer prevention?
Always wear shows
Check fit of footwear
Check pressure points/planter surface of foot regularly
Prompt and regular wound care of skin breaches
Effective glycaemic control
What does the management of diabetic foot ulcers involve?
Prevention
Diligent wound care
Infection
Investigate for osteomyelitis, gas gangrene, necrotising fascitis
Revascularisation (very distal disease)
Amputation
Adjunctive measures
Where are different amputations for diabetic foot disease?
Hip dislocation
Above knee
Through knee
Below knee
Symes
Trans-metatarsal
Digital
