Arterial Disease of the Limbs - Presentation, Investigation & Therapy Flashcards
What anatomy from the aorta at the top of the leg to the bottom of the leg at the foot
Aorta - iliac arteries - common femoral artery - superficial femoral artery - popliteal artery;
- 1.anterior tibial- dorsalis pedis
- peroneal artery
- posteroir tibial artery
What is the definition chronic limb ischaemia
Atherosclerotic disease of the arteries supplying the lower limbs
What is the possible aetiologies of Chronic limb lischaemia
Atheosclerotic
vasculitis
buergers disease
What is the risk factors for Chronic limb ischaemia
Male Age Smoking Hypercholesterolaemia Hypertension Diabetes
What is stages of symptoms of CLI
- Asymptomatic, incomplete blood vessel obstruction
- Mild claudication pain in limb
A. walking more than 200m
B. walking less than 200m - Rest pain, mostly in feet
- Necrosis and/or gangrene of the limb
Claudication definition
a condition in which cramping pain in the leg is induced by exercise
In diagnosing, what factors need to be considered with a presenting history of claudication
Exercise tolerance, effect of incline, does it change over time, is it relieved by rest Where in the leg is the pain, type of pain is it Bilateral
In diagnosing what factors needs to be considered with a
history of
- rest pain
- tissue loss
- character of the pain
is there any relieving factors
2.Duration
History of trauma
peripheral sensation
What is the signs of chronic ischaemia in the legs
Ulceration
Pallor
Hair loss
In examination of chronic ischaemia of the leg what should you examine for
PALPABLE Capillary refill times Temperature Pulses – start at the aorta Peripheral sensation
AUSCULTATE
auscultate for Dorsalis pedis and posterior tibial pulses if they are not palpable
What is the two special tests tried on examination
Ankle brachial pressure index
Buergers test
What does the ankle brachial pressure index show if it is
- less than 1
- 0.95 -0.5
- less than 0.2
- ischaemia in the legs
- claudication present
- gangrene and ulceration is occuring
What is the investigations and sign in the buergers test
Elevation of legs - show pallor
Hanging feet of the bed - slow to regain colour as shows a dark red colour
Why does a dark red colour appear as you hang your feet of the bed
As all the the capillaries are open - so fills with blood rapidly = red
How could you test for severe ischaemia in burgers test
If pallor appears at elevation of legs at 20 degrees
What is the best medical therapy treatments for CLI
Antiplatelet therapy statin therapy BP control Smoking cessation Diabetic control Exercise
- same management as CAD
Patients with CLI can potentially have an under diagnosis of what
Diabetes
What is the management of CLI when the symptoms become severe
angioplasty/stent
surgical bypass
Amputation
What imagery investigations are used in the diagnosis in CLI
Duplex
CTA/MRA
Digital subtraction angiogram
What is the advantages and disadvantages to Duplex imaging
Advantage
Dynamic
No radiation/contrast
Disadvantage
Not good in the abdomen
Operator dependent, time consuming
What is first line imaging in diagnosis in peripheral arterial disease and why
CT/MRI – allows treatment planning
What is the disadvantage of CT/MRI imaging in diagnosing peripheral arterial disease
Contrast and radiation
Can overestimate calcification, difficulty in low flow states
What is Digital subtraction angiogram and what does it increase the risk of
type of fluoroscopy technique used in interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue environment.
haematoma or infection
What is duplex imaging
form of medical ultrasonography that incorporates that involves imaging of structure and flow of movement of structure
What is the requirements for surgical bypass
Inflow
A conduit: autologous (vein from legs, arm), synthetic (PTFE/Dacron)
Outflow
What is the general risk of complications in surgical bypass
Bleeding, wound infection, pain, scar, DVT, Pulmonary Embolism, MI, CVA, LRTI, death (2%)
What is the technical risks of complication in surgical bypass
Damage to nearby vein, artery, nerve,
distal emboli,
graft failure (stenosis, occlusion)
What is the procedure formed in a surgical bypass
restoring normal blood supply to the heart by creating new routes for the blood to travel into the heart when one or both of the coronary arteries have become clogged
What is the two forms of surgical procedures for server peripheral ischeamia
Bypass first or angioplasty
amputation
What is in the survival procedure of an angioplasty
procedure that can open up a blocked blood vessel using a small, flexible plastic tube, or catheter, with a “balloon” at the end of it. When the tube is in place, it inflates to open the blood vessel, or artery, so that normal blood flow is restored
What determines what surgical treatment patients should have between angioplasty and bypass
If patients expected to live <2 years should have angioplasty first.
If life expectancy >2yrs, and they have vein, should have bypass first.
What follows surgical amputation
rehabilitation
What is the definition of acute limb ischaemia
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 aeitology of acute limb ischameia
Arterial embolus:
Thrombosis:
Usually thrombosis of a previously diseased artery due to MI, AF, proximal atherosclerosis
Trauma
Dissection
Acute aneurysm thrombosis i.e. popliteal
What is the history that needs to be gathered form presentation of acute limb ischameia
History of chronic limb ischaemia Risk factors for CLI Cardiac history Onset/duration of symptoms Functional status - can they walk on it Social history
What are the 6P’s in the presentation of ALI
Pain Pallor Perishingly cold Paraesthesia Paralysis Pulseless (compared in both legs)
What is the pathology and presentation of compartment syndrome
Muscle ischaemia causes inflammation which leads to oedema and results in venous obstruction
Presentation: Tense and tender calf
What enzyme does compartment syndrome increase in the legs
Creatinine kinase -a protein necessary for muscle cells of the body to achieve their different chemical reactions
What does compartment syndrome increase the risk of
renal failure (myoglobulinaemia)
What is the investigations for ALI
ECG
Bloods
What is the medical treatment for management of ALI
Anti coagulate
anlagesia
What is the management of the limb is not salvageable in ALI
Either amputation
If there is a suspicion of embolus in ALI what is the management
Embolectomy
If there is a suspicion of a thrombosis in situ what is the management
Mechanical thrombectomy
Thrombolysis
Open embolectomy bypass
Why is acute limb ischaemia considered a medical emergency
Because it becomes irreversible after 6-8hours
What is the pathophysiology of diabetic disease
Microvascular peripheral artery disease
Peripheral neuropathy
Mechanical imbalance
Susceptibility to infection
What is the foot care recommendations for diabetics
Always wear shoes
Check fit of footwear
Check pressure points/plantar surface of foot regularly
Prompt and regular woundcare of skin breaches
what is the management for foot disease in diabetics
Prevention
Good wound care
Tracking infection – consider systemic antibiotics
Investigate for osteomyelitis, gas gangrene, necrotising fasciitis
What is the surgical management for diabetic foot disease
Revascularation - Angioplasy / Bypass
Amputation
What is the disadvantages to revascularation
Limited success of endovascular/surgical revascularisation (distal disease)
stent doesn’t stay well in small vessels
