Arterial Diseases of the Limbs

Question 1

What does the aorta split into in the pelvis?

Answer 1

Iliac arteries

Question 2

What does the iliac arteries split into?

Answer 2

Common femoral

Question 3

Branches of the superficial femoral artery

Answer 3

Popliteal 
Anterior tibial 
Peroneal 
Posterior tibial 
Dorsalis pedis

Question 4

Where do you feel the common femoral artery?

Answer 4

Mid inguinal point, half way between anterior superior iliac spine and the pubic symphysis

Question 5

Where do you feel the popliteal artery?

Answer 5

Deep in popliteal fossa

Question 6

Where do you feel posterior tibial pulse?

Answer 6

Half way between the medial malleolus and the achilles tendon

Question 7

Where do you feel the dorsalis pedis pulse?

Answer 7

Lateral to the extensor hallicus longus tendon

Question 8

Causes of critical limb ischaemia

Answer 8

Atherosclerotic disease of arteries supplying lower limb
Vasculitis
Buergers disease

Question 9

Risk factors for critical limb ischaemia

Answer 9

Male
Age
Smoking
Hypercholesteraemia
HTN
DM

Question 10

Classification system of critical limb ischaemia

Answer 10

Fontaine classification

Question 11

Stages of Fontaine classification of critical limb ischaemia

Answer 11

Stage I - asymptomatic, incomplete blood vessel obstruction
Stage II - mild claudication, pain in the limb
Stage IIA - claudication when walking > 200metres
Stage IIB - claudication when walking < 200metres
Stage III - Rest pain, mostly in feet
Stage IV - Necrosis and/or gangrene of the limb

Question 12

Why would you get pain in feet at night with critical limb ischaemia?

Answer 12

BP drops at night and the way you are sitting - the perfusion would decrease at night and therefore cause the pain

Question 13

What to ask about the claudication

Answer 13

Exercise tolerance
Effect of incline
Change over time
Relieved by rest
Where in the leg 
Type of pain 
Bilateral or one leg
Distance they walk when it starts 
Rest pain

Question 14

What type of pain is claudication usually?

Answer 14

Burning

Question 15

Signs of chronic ischaemia in lower limbs

Answer 15

Ulceration
Pallor
Hair loss

Question 16

Investigations for critical limb ischaemia

Answer 16

Examination 
Auscultate (hand held doppler)
Ankle brachial pressure index (pressure)
Buergers test 
Hang feet off edge of bed 
Duplex 
CTA/MRA
Digital subtraction angiogram

Question 17

ABPI in normal vasculature value

Answer 17

equal or > 1

Question 18

ABPI in intermittent claudication

Answer 18

0.95 - 0.5

Question 19

ABPI in rest pain

Answer 19

0.5 - 0.3

Question 20

What is buergers test?

Answer 20

Elevate legs for pallor and beurgers angle, <20 degrees = severe ischaemia

Question 21

What would you see if the feet are hung off the bed in claudication and what is this called?

Answer 21

Slow to regain colour and a dark red colour as the blood rushes in and the feet become red
Hyperaemic sunset foot

Question 22

1st line investigation for critical limb ischaemia

Answer 22

CTA/MRA

Question 23

Definition of emboli

Answer 23

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

Question 24

Definition of thrombus

Answer 24

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

Question 25

Sources of arterial embolus

Answer 25

MI AF Proximal atherosclerosis

Question 26

Causes of acute limb ischaemia

Answer 26

``` Arterial embolus Thrombus Trauma Dissection Acute aneurysm thrombosis i.e. popliteal ```

Question 27

Presentation of acute limb ischaemia

Answer 27

6 Ps!!! - Pain - Pallor - Perishingly cold - Paraesthesia - Paralysis - Pulseless

Question 28

Irreversibility will occur how long after symptoms present in acute limb ischaemia?

Answer 28

> 6 hours

Question 29

Pathology of compartment syndrome

Answer 29

Muscle ischaemia Inflammation Oedema Venous obstruction

Question 30

Presentation of compartment syndrome of lower limb

Answer 30

Tense, tender calf

Question 31

What is raised in compartment syndrome?

Answer 31

Creatinine kinase

Question 32

Management of acute limb ischaemia

Answer 32

``` ECG Bloods Analgesia Anticoagulation Suspicion of embolus - embolectomy Suspicion of thrombus - thrombectomy/thrombolysis, open embolectomy +/- bypass Amputation Palliation ```

Question 33

Mortality of amputation

Answer 33

20%

Question 34

What % of acute limb ischaemia is due to emboli and to thrombus?

Answer 34

30% emboli | 60% thrombosis

Question 35

Mortality of acute limb ischaemia

Answer 35

22%

Question 36

What % of patients with DM will develop a foot ulcer?

Answer 36

15%

Question 37

What is key in managing diabetic foot ulcers?

Answer 37

Prevention

Question 38

Prevention of diabetic foot ulcers

Answer 38

Footcare Glycaemic control Good wound care Tracking infection (consider systemic Ax)

Question 39

Pathology of diabetic foot disease

Answer 39

Microvascular peripheral artery disease affecting capillary beds - stiffening of capillaries, inflammation etc Peripheral neuropathy - risk of trauma - standing on things without realising etc Mechanical imbalance - pressure points in odd places and tissue damage in these areas Susceptibility to infection (via normal skin commensals)

Question 40

Footcare in DM

Answer 40

Always wear shoes Check fit Check pressure points / plantar surface of foot regularly Prompt and regular wound care of skin breaches

Question 41

What should be investigated for in diabetic foot disease?

Answer 41

Osteomyelitis Gas gangrene Necrotising fasciitis

Question 42

Management of chronic limb ischaemia

Answer 42

``` Anti-platelet Statin BP control Smoking cessation Exercise Diabetic control Angioplasty/stent Surgical bypass Endovascular reconstruction ```

Question 43

What can be used as a surgical bypass?

Answer 43

Femoral popliteal bypass Femoral distal bypass to calves Anatomical bypass - aorta to both femorals Extra anatomical bypass Axillo anatomical bypass (axilla to femoral))

Question 44

What does a surgical bypass require?

Answer 44

``` Inflow above the blood flow A conduit - autologous - synthetic Outflow ```

Question 45

Complications of surgical bypass

Answer 45

``` Bleeding Wound infection Pain Scar DVT / PE / MI Death (2%) Damage to nearby structures Graft failure (stenosis / occlusion) Distal emboli ```

Question 46

ABPI in diabetics

Answer 46

Higher

Question 47

What may T2DM have to do with their vessels and therefore how does this effect their ABPM?

Answer 47

Vessel classification | Abnormally high ABPM readings

Question 48

What is Buergers disease also known as?

Answer 48

Thromboangiitis obliterans

Question 49

What is buergers disease?

Answer 49

Small and medium vessel vasculitis that is strongly associated with smoking

Question 50

Features of buergers disease

Answer 50

``` Extremity ischaemia - intermittent claudication - ischaemic ulcers Superficial thrombophlebitis Raynauds phenomenon ```