Arterial diseases of the limbs Flashcards
What is the pathophysiology of peripheral vascular disease ?
Atherosclerotic disease of arteries supplying the lower limb
Less commonly: vasculitis, Buerger’s disease
Same disease process as cornoary and carotid atherosclerotic disease
What is the risk factors of PVD ?
Male Age Smoking Hypercholesterolemia Hypertension Diabetes
How are the symptoms of PVD classified ?
Fontaine classification
What is stage I on Fontaine classification ?
Asymptomatic, incomplete blood vessel obstruction
What is stage II on Fontaine classification ?
Mild claudication pain in limb
Stage IIA: claudication when walking a distance >200m
Stage IIB: claudication when walking a distance <200m
What is stage III on Fontaine classification ?
Rest pain, mostly in the feet
What is stage IV on Fontaine classification ?
Necrosis and gangrene of the limb
What is useful in the history of PVD ?
Claudication Rest pain Tissue loss Risk factors Past medical history Surgical history
What should we look for on examination of PVD ?
Signs of chronic ischaemia:
- ulceration
- pallor
- hair loss
What should we feel for on examination of PVD ?
Temperature
Capillary refill time
Peripheral sensation
Pulses- start at aorta
What should we auscultate on examination of PVD ?
Hand help doppler
Dorsalis pedis and posterior tibial pulses
What are special tests for PVD ?
Ankle brachial pressure index
Buerger’s test
What are the investigations for PVD ?
Duplex: - dynamic - no radiation/ contrast - not good in abdomen CTA/MRA: - detailed- allows treatment planning - first line according to NICE - contrast and radiation Digital subtraction angiography
What is the best medical therapy of PVD ?
Combination of:
- antiplatelet- reduces risk of requiring revascularisation as well as CV
mortality
- statin- inhibits platelet activation and thrombosis, lowers cholesterol
How should we control the risk factors in PVD ?
BP control
Smoking cessation
Diabetic control
What surgery can be used for PVD ?
Bypass and or endarterectomy
What is endovascular intervention ?
Balloon angioplasty
Stent placement
Atherectomy
What is acute limb ischamia ?
Embolis carried in blood stream and lodges in a vessel causing obstruction
What is the pathophysiology of acute limb ischaemia ?
Arterial embolus- MI, AF Thrombosis Trauma Dissection Acute aneurysm Thrombosis
What is the clinical presentation of acute limb ischaemia ?
Pain Pallor Pulse deficit Paraesthesia Paresis/paralysis Poikilothermia (cold) Compare to contralateral limb
What is useful in the history of acute limb ischaemia ?
Cardiac history Onset/duration of symptoms History of chronic limb ischamia Risk factors for CLI Functional status
What is compartment syndrome ?
Muscle ischaemia Inflammation, oedema, venous obstruction Tense, tender calf Rise in creatinine kinase Risk of renal failure
What % of diabetics will develop diabetic foot disease/ ulcer ?
25%
What % of DFU become infected ?
50%
What % of DFD require amputation ?
20%
What is the pathophysiology of diabetic foot disease ?
Microvascular peripheral artery disease Peripheral neuropathy Mechanical imbalance Foot deformity Minor trauma Susceptibility to infection
How can DFD be prevented ?
Always wear shoes- avoid minor injuries
Check fit of footwear
Check pressure points/ plantar surface of foot regularly
Prompt and regular wound care of skin breaches
Effective glycaemic control
What is the management of DFD ?
Prevention Diligent wound care Infection-> systemic antibiotics Investigate for osteomyelitis, gas gangrene, necrotising fasciitis Revascularisation- very distal disease Amputation Dressings Debridement- larval therapy Negative pressure wound closure Skin grafts
