Arterial Disease of the Limbs: Presentation, Investigation and Therapy Flashcards
What pulse points should be examined?
- Aorta
- Common femoral artery
- Popiteal artery
- Posterior tibial pulse
- Dorsalis pedis
Pulse point: aorta
Above the umbilicus. Use 2 hands to feel for pulsation vs expansion
Pulse points: common femoral artery
Mid-ingual point, 1/2 between the anterior superior iliac spine and the pubic symphysis
Pulse points: popiteal artery
Use both hands to feel deep in the popliteal fossa- leg relaxed into your hands
Pulse points: posterior tibial pulse
1/2 way between the medial malleolus and the Achilles tendon
Pulse points: dorsalis pedis
Lateral to the extensor halluces longus tendon
What are the risk factors for CLI?
- Male
- Age
- Smoking
- Hypercholesterolemia
- Hypertension
- Diabetes
What is the pathophysiology of CLI?
- Atherosclerotic disease of the arteries supplying the lower limb
- Less commonly vasculitis, Buerger’s disease
What does CLI follow the same disease process as?
- Coronary atherosclerosis
- Carotid atherosclerosis
What are the Fontaine classifications of symptoms?
- Stage I
- Stage IIA
- Stage IIB
- Stage III
- Stage IV
Fontaine classification: stage I
Asymptomatic, incomplete blood vessel obstruction
Fontaine classification: stage IIA
Claudication when walking a distance of greater than 200m
Fontaine classification: stage IIB
Claudication when walking a distance of less than 200m
Fontaine classification: stage III
Rest pain, mostly in feet
Fontaine classification: stage IV
Necrosis and /or gangrene of the limb
What may there be history of?
- Claudication
- Rest pain
- Tissue loss
What must be considered during the history when making a diagnosis?
- Risk factors
- PMH
- DH
- SH
- OH
What details about any claudication should you find out?
- Exercise tolerance
- Effect of incline
- Change over time
- Relieved by rest?
- Location
- Type of pain
- Bilateral?
What details about any rest pain should you find out?
- Type of pain
- Relieving factors
What details about ant tissue loss should you find out?
- Duration
- History of trauma
- Peripheral sensation
What should you look for on examination of both legs?
Signs of chronic ischaemia:
- Ulceration
- Pallor
- Hair loss
What should you feel for on examination of the legs?
Start at toes, compare both sides:
- Cap refill
- Temp
- Pulses (start at aorta)
- Peripheral sensation
How should auscultation be carried out?
Hand held doppler
What should be ausculatated?
- Dorsalis pedis
- Posterior tibial pulses
What special tests should be carried out on examination?
- Ankle brachial pressure index
- Buerger’s test
What is the ankle brachial pressure index?
Ankle pressure divided by the brachial pressure
What are the clinical statuses on the ankle brachial pressure index?
-Symptom free: 1+
-Intermittent claudication: 0.95-0.5
-Rest pain: 0.5-0.3
Gangrene and ulceration: <0.2
How is Buerger’s test performed?
- Elevate legs (pallor, Bueger’s angle< 20 degrees severe ischaemia)
- Hang feet over the bed (slow to regain colour, dark red colour)
How many capillaries are normally open?
1/3
What causes hyperaemic sunset foot?
CLI autoregulation is lost causing all capillaries to open
What is involved in best medical therapy?
- Antiplatelet
- Statin
- BP control
- Smoking cessation
- Exercise
- Diabetic control
What do antiplatelets do?
Reduce risk of requiring revascularisation as well as reducing CV and all cause mortality
What do statins do?
Inhibits platelet activiation and thrombosis, endothelial and inflammation activation, plaque rupture
What is the target BP?
<140/85
What does smoking cessation lead to?
Excess risk of CV disease diminishes within 4-6yrs
What does exercise lead to?
150% improvement in waling time
What does diabetic control lead to?
10% of PAD are undiagnosed diabetics. Tight glycaemic control prevents microvascular disease
How should those with mild to moderate symptoms be managed?
BMT only
How should those with sever symptoms be managed?
- BMT
- Angioplasty/stent
- Surgical bypass
How should those with critical symptoms be managed?
- BMT
- Angioplasty/stent/endovascular reconstruction/surgical bypass
What imaging should be carried out in the investigation?
- Ultrasound
- CT
What are the advantages of ultrasound?
- Dynamic
- No radiation/ contrast
What are the disadvantages of ultrasound?
- Not good in the abdomen
- Operator dependent, time consuming
What are the advantages of CT?
- Detailed- allows treatment planning
- First line according to NICE
What are the disadvantages of CT?
- Contrast and radiation
- Can overestimate calcification, difficulty in low flow states
How can iliac occlusion be bypassed?
- Iliac angioplasty and crossover graft
- Aortaobifemoral bypass graft
- Axillobifemoral bypass graft
What does surgical bypass require?
- Inflow
- A conduit
- Outflow
What can be used as conduits for surgical bypass?
- Autologous (vein from legs, arm)
- Synthetic (PFTE/Dacron)
What general complication risks are there with surgical bypass?
- Bleeding
- Wound infection
- Pain
- Scar
- DVT
- PE
- MI
- CVA
- LRTI
- Death
What technical complication risks are there with surgical bypass?
- Damage to vein
- Damage to artery
- Damage to nerve
- Distal emboli
- Graft failure
What types of amputation may be performed if perfusion to the leg is lost?
- Hindquarter (v rare)
- Hip disarticulation (v rare)
- Above knee
- Through knee
- Below knee
- Symes (v rare)
- Transmetatarsal
- Digit
What do amputees need to regain during rehabilitation?
- Mobility
- Energy requirements
How does the energy requirements differ fro BKA and AKA?
- BKA: 63% increase
- AKA: 117% increase
Emboli
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 embolism
Thrombus
A blood clot formed in situ within the vascular system of the body and impeding blood flow
What is the pathophysiology of ALI?
- Arterial embolus (MI, AF, proximal atherosclerosis)
- Thrombosis (usually thrombosis of a previously diseased artery)
- Trauma
- Dissection
- Acute aneurysm thrombosis
What should be discussed when taking the history of someone presenting with ALI?
- History of CLI
- Risk factors for CLI
- Cardiac history
- Onset/ duration of symptoms
- Functional status/ SH
What are the 6 Ps in the presentation of ALI?
- Pain
- Pallor
- Perishingly cold
- Paralysis
- Pulseless
- Paraesthesia
What can cause compartment syndrome?
- Muscle ischaemia
- Inflammation
- Oedema
- Venous obstruction
What is there a risk of in compartment syndrome?
Renal failure (myoglobulinaemia)
What is there a is in in compartment syndrome?
Creatinine kinase
What is the presentation of compartment syndrome in the leg?
Tense, tender calf
How should ALI be managed?
- ECG
- Bloods
- Nil by mouth
- Analgesia
- Anticoagulate
How can embolectomy be carried out?
- Under GA
- Under LA
When does irreversible muscle ischaemia occur?
6-8 hrs
What is the mortality rate of ALI?
22%
What percentage of diabetics will develop a foot ulcer in their lifetime?
15%
What is the pathophysiology of diabetic foot disease?
s-Microvascular peripheral artery disease
- Peripheral neuropathy
- Mechanical imbalance
- Susceptibility to infection
What footcare should diabetics have?
- Always wear shoes
- Check fit of footwear
- Check pressure points/ plantar surface of foot regularly
- Prompt and regular wound care of skin breaches
How can diabetic foot disease be managed?
- Prevention
- Good wound care
- Tracking infection
- Investigate for osteomyelitis, gas gangrene, necrotising fasciitis
- Revascularisation
- Amputation
What revascularisation techniques can be used in diabetic foot disease management?
- If the disease is very distal then attempt distal crural angioplasty/ stent
- Distal bypass
