Arterial Diseases of the Limbs

Question 1

What does the aorta divide into?

Answer 1

Two iliac arteries

Question 2

What does the detection of a normal pulse confirm?

Answer 2

There is no significant stenosis or occlusion within the lumen of an artery

Question 3

What is chronic limb ischaemia?

Answer 3

Atherosclerotic disease of the arteries supplying the lower limb

Question 4

What are the risk factors for chronic limb ischaemia?

Answer 4

Male
Age
Smoking
Hypercholesterolemia
Hypertension
Diabetes

Question 5

In which decade of life can atheromatous disease form?

Answer 5

3rd decade

Question 6

In which decade of life can complicated plaques start to develop?

Answer 6

4th decade

Question 7

Which classification system can be used to classify symptoms?

Answer 7

Fontaines Classification

Question 8

What is stage one of Fontaines Classification?

Answer 8

Asymptomatic, incomplete blood vessel obstruction

Question 9

What is stage 2A of Fontaines Classification?

Answer 9

Mild claudication pain in limb
Claudication when walking a distance of greater than 200 meters

Question 10

What is stage 2B of Fontaines Classification?

Answer 10

Mild claudication pain in limb
Claudication when walking a distance of less than 200 meters

Question 11

What is stage three of Fontaines Classification?

Answer 11

Rest pain, mostly in the feet

Question 12

What is stage four of Fontaines Classification?

Answer 12

Necrosis and/or gangrene of the limb

Question 13

Which stages of Fostaines Classification indicate critical limb ischaemia?

Answer 13

Stage III or IV

Question 14

Which questions would you ask in a history if a patient has claudification?

Answer 14

Level of exercise tolerance, effect of incline, change over time, relieved by rest? Where in the leg, type of pain. Bilateral?

Question 15

Upon examination, what are some of the signs of chronic ischaemia?

Answer 15

Ulceration
Pallor
Hair loss

Question 16

What are the types of imaging you might use with someone with chronic limb ischaemia?

Answer 16

Duplex ultrasonography
MRA/CTA
Digital subtraction angiography

Question 17

What is the first line imaging investigation for those with chronic limb ischaemia?

Answer 17

Duplex ultrasonography

Question 18

What are the pros/cons for duplex ultrasonography?

Answer 18

Pros- dynamic, no radiation/contrast
Cons- Not good in the abdomen, operator dependant time consuming

Question 19

What are the pros/cons for MRA/CTA (MRI/CT angio)?

Answer 19

Pros- detailed so help with planning next steps
Cons- contrast and radiation

Question 20

Which types of drug make up the best medical therapy to manage chronic limb ischaemia?

Answer 20

Antiplatelet and a stain

Question 21

Discuss how control of risk factors can reduce risks of chronic limb ischaemia.

Answer 21

Reduction of BP to <140/85 can help
Smoking cessation
Diabetic control
More exercise

Question 22

What are the two revascularization procedures which can be done in patients with chronic limb ischaemia?

Answer 22

Open surgery
Endovascular intervention

Question 23

What are some of the open revascularisation surgeries used for management of chronic limb ischaemia?

Answer 23

Bypass and/or endarterectomy

Question 24

What are some of the endovascular revascularisation surgeries used for management of chronic limb ischaemia?

Answer 24

Balloon angioplasty
Stent placement
Atherectomy

Question 25

Define embolus.

Answer 25

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.

Question 26

Define thrombus.

Answer 26

A blood clot formed in situ within the vascular system of the body and impeding blood flow.

Question 27

What can cause acute limb ischaemia?

Answer 27

Embolus or a thrombus

Question 28

What is the clinical presentation for a patient with acute limb ischaemia?

Answer 28

6 P's :) Pain Pallor Pulse deficit Paraesthesia Paresis/Paralysis Poikilothermia (cold)

Question 29

What does paraesthesia mean?

Answer 29

A burning/prickly feeling

Question 30

After how much time is muscle ischaemia irreversible?

Answer 30

6-8 hours

Question 31

What can irreversible muscle ischemia cause to happen?

Answer 31

Inflammation, oedema, venous obstruction All those cause calve tenderness

Question 32

Describe the findings of someone with marginally threatening limb ischaemia.

Answer 32

Minimal sensory loss- sometimes toes No muscle weakness Inaudible doppler signals Audible doppler signals

Question 33

Describe the findings of someone with immediately threatening limb ischaemia.

Answer 33

Some sensory loss- more than toes Mild/ moderate muscle weakness Inaudible doppler signals Audible doppler signals

Question 34

Describe the findings of someone with marginally threatened limb ischaemia.

Answer 34

Profound sensory loss Profound muscle loss/ paralysis Inaudible arterial doppler signals Inaudible venous doppler signals

Question 35

In acute limb ischaemia, if the limb is salvageable and there is a suspicion of embolus, what can be done?

Answer 35

Embolectomy

Question 36

In acute limb ischaemia, if the limb is salvageable and there is a suspicion of thrombosis, what can be done?

Answer 36

Endovascular: mechanical thrombectomy / thrombolysis OR Open embolectomy +/- bypass

Question 37

In acute limb ischaemia, what are the management options if the limb is not salvageable?

Answer 37

If the patient is willing, amputate it. If not, palliative management.

Question 38

What % of diabetic patients will develop foot disease?

Answer 38

25%

Question 39

What % of diabetic foot ulcers become infected?

Answer 39

50%

Question 40

Aetiology of diabetic food disease is usually multifactorial. Therefore, list some of the causes of diabetic foot disease.

Answer 40

Microvascular peripheral artery disease Peripheral neuropathy Mechanical imbalance Foot deformity Minor trauma Susceptibility to infection

Question 41

Prevention is always better than cure :) What preventative measures can reduce risks of diabetic foot ulcers?

Answer 41

Avoid walking barefoot Ensure footwear are good fit Check pressure points of the foot regularly Prompt, regular wound care of any skin breaches

Question 42

If you notice infection of a foot ulcer, what should the immediate treatment be?

Answer 42

Antibiotics

Question 43

What are some of the management options for individuals with diabetic foot ulcers/disease?

Answer 43

Revascularisation Amputation

Question 44

What are some adjunctive* measures for foot ulcers? *supplement

Answer 44

Dressings Debridement – Larval therapy Negative Pressure Wound Closure Skin grafts