Arterial Disease of the Limbs - Presentation, Investigation & Therapy

Question 1

Name the arteries

Answer 1

Question 2

How do you examine for the aortic pulse?

Answer 2

——Above the umbilicus. Use two hands to feel for pulsation vs expansion

Question 3

How do you feel for the common femoral artery?

Answer 3

—Mid-inguinal point, ½ way between the Anterior Superior Iliac Spine and the pubic symphysis

Question 4

How do you feel for the popliteal artery?

Answer 4

—Use both hands to feel deep in the popliteal fossa – leg relaxed into your hands

Question 5

How do you find the posterior tibial pulse?

Answer 5

—: ½ way between the medial malleolus and the achilles tendon

Question 6

How do you find the dorsalis pedis pulse?

Answer 6

Lateral to the extensor hallucis longus tendon

Question 7

What is the cause of CLI (critical limb ischaemia)?

Answer 7

—Atherosclerotic disease of the arteries supplying the lower limb

Question 8

What are the risk factors for CLI?

Answer 8

—Male

—Age

—Smoking

—Hypercholesterolaemia

—Hypertension

—Diabetes

Question 9

What is stage 1 CLA according to the Fontaine classification?

Answer 9

—Stage I: Asymptomatic, incomplete blood vessel obstruction

Question 10

What is stage 2 CLA according to the Fontaine classification?

Answer 10

—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

Question 11

What is stage 3 CLA according to the Fontaine classification?

Answer 11

—Stage III: Rest pain, mostly in the feet

Question 12

What is stage 4 CLA according to the Fontaine classification?

Answer 12

—Stage IV: Necrosis and/or gangrene of the limb

Question 13

Which leg does claudication usually impact?

Answer 13

Bilateral

Question 14

What is typical past medical history for CLI?

Answer 14

—Other signs of atherosclerosis (MI, Stroke?)

Question 15

What drug might a CLI patient be taking?

Answer 15

control of diabetes, aspirin?

Question 16

What is the significance of a CLA patient occupation?

Answer 16

Determines the type of treatment

Question 17

What are the signs of chronic ischaemia on examination?

Answer 17

Ulceration

Pallor

Hair loss

Question 18

What should you feel during examination of CLA?

Answer 18

Capillary refill times

Temperature

Pulses

Peripheral sensation (particularly in diabetics)

STARTING AT TOES AND ALWAYS COMPARING SIDES

Question 19

How do you auscultate for CLA?

Answer 19

Hand held doppler (ultrasound machine)

Listening to the dorsalis pedis and the posterior ribial pulses

Question 20

What is the ankle brachial pressure index and what does it indicate?

Answer 20

Ratio of ankle pressure over brachial pressure

When exercising should be greater than one since leg muscles need lots of O2 so increased blood flow.

At rest the ration should be around 1 less than 1 indicates obstruction of blood flow

Question 21

What is the buerger’s test?

Answer 21

Elevate legs - pallor below a 20 degree angle indicates severe ischaemia

Hang feet over the edge of the bed - slow to regain colour, should progress to —Dark red colour (hyperaemic sunset foot).

Question 22

Why does hanging feet over the edge of a bed cause CLI patients’ feet to become hyperaemic?

Answer 22

Normally only 1/3 of the capillaries are open. In CLI all capillaries are open and autoregulation is lost

Question 23

What is peripheral vascular disease treated the same way as?

Answer 23

Should be managed the same way as those with established CHD

Question 24

What is best medical therapy?

Answer 24

—Antiplatelet

—Statin: Inhibits platelet activation and thrombosis, endothelial and inflammation activation, plaque rupture

—BP control: Target <140/85

—Smoking cessation

—Exercise: 150% improvement in walking time – body will develop own collaterals with neo-angiogenesis

—Diabetic control: 10% of PAD patients are undiagnosed diabetics. Tight glycaemic control prevents microvascular disease

Question 25

What type of therapy is best for 1. Moderate symptoms 2. Severe symptoms 3. Critical symptoms

Answer 25

Moderate - BMT only Severe - BMT, angioplasty/stent, surgical bypass Critical - BMT, angioplasty / stent / endovascular reconstruction / surgical bypass

Question 26

What are the possible imaging investigations for CLI?

Answer 26

Duplex (ultrasonography where structure or architecture of the body part is captured and flow or movement of a structure is visualized) CT/MRA Digital subtraction angiogram (angiography)

Question 27

What are the advantages and disadvantages of Duplex?

Answer 27

Advantages: ## Footnote —Dynamic – assess flow as well as anatomy —No radiation/contrast Disadvantages: —Not good in the abdomen (iliacs) —Operator dependent, time consuming

Question 28

What are the benefits of CT/MRA

Answer 28

Advantages: ## Footnote —Detailed – allows treatment planning —First line according to NICE Disadvantages: Uses Contrast and Radiation —Can overestimate calcification, difficulty in low flow states (difficult if there is terrible heart failure and the contrast can’t really reach the feet)

Question 29

What are the possible conduits for surgical bypass?

Answer 29

Reversed saphenous vein

Question 30

What does surgical bypass require?

Answer 30

Inflow A conduit Outflow

Question 31

Why is an autologous conduit better than a synthetic one?

Answer 31

Risk of infection is worse

Question 32

What are the general risks / complications of surgical bypass?

Answer 32

Bleeding, wound infection, pain, scar, DVT, PE, MI, stroke, death (2%)

Question 33

What are the technical risks / complications of surgical bypass?

Answer 33

Damage to nearby vein, artery, nerve, distal emboli, graft failure (stenosis, occlusion)

Question 34

What is reintervention rate for surgical bypass?

Answer 34

18.3 – 38.8% (higher if smoking)

Question 35

What are 5 year patency rates of surgical bypass?

Answer 35

45-73%

Question 36

What are the types of amputation from the hip down?

Answer 36

Question 37

Which type of amputation requires more energy? BKA or AKA (above or below the knee amputation)

Answer 37

—63% higher in BKA —117% higher in AKA

Question 38

What are the different ways an embolus can arise?

Answer 38

MI, AF, proximal atherosclerosis (not DVT/PE these are linked to venous disease) Trauma Dissection Acute aneurysm thrombosis

Question 39

What is the point in finding out the onset/duration of symptoms?

Answer 39

Lets you know the likely prognosis

Question 40

What are the 6 P's of presentation?

Answer 40

—Pain —Pallor —Perishingly cold —Paraesthesia —Paralysis —Pulseless —Compare to contralateral limb

Question 41

What is compartment syndrome?

Answer 41

Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.

Question 42

In this case what causes the acute compartment syndrome?

Answer 42

This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours. Rise in creatine kinase - risk of renal failure since creatine is amssive

Question 43

What is management of acute limb ischaemia?

Answer 43

ECG, bloods, nil by mouth Analgesia Anticoagulate (heparin - allows chance of blood getting through occlusion)

Question 44

What is management of a salvagable limb in ALI management?

Answer 44

If embolus - embolectomy If thrombus - Endovascular :mechanincal thrombectomy/thrombolysis or open embolectomy +/- bypass

Question 45

What type of anaesthetic is used for embolectomy?

Answer 45

General or local

Question 46

What is the likely cause for ALI?

Answer 46

—30% embolic, 60% thrombosis in situ

Question 47

When does irreversible muscle ischaemia occur?

Answer 47

In 6-8 hours

Question 48

What is the pathophysiology of diabetic foot disease?

Answer 48

Microvascular peripheral artery disease ## Footnote —Peripheral neuropathy – they lose sensation of their foot – more likely chance of trauma —Mechanical imbalance – lose proprioception and walk differently – pressure points different and now damaged —Susceptibility to infection

Question 49

How do you ensure footcare of a diabetic?

Answer 49

Always wear shoes Check fit of footwear Check pressure points of foot regularly Prompt and regular woundcare

Question 50

What is diabetic foot management?

Answer 50

—_Prevention_ _—Good wound care_ _—Tracking infection_ (lymphangitis or cellulitis)– consider systemic antibiotics _—Investigate_ for osteomyelitis, gas gangrene, necrotising fasciitis _—Revascularisation_ —Disease is very distal – attempt distal crural angioplasty / stent —Distal bypass _Amputation_