Arterial Limb Disease

Question 1

What are the 3 types of Arterial Limb Disease (Peripheral Arterial Disease)?

Answer 1

Critical Limb Ischaemia (CLI)
Acute Limb Ischaemia (ALI)
Diabetic Foot Disease

Question 2

What is CLI?

Answer 2

Long term loss of blood flow to limb tissue due to stenosis/occlusion of peripheral arteries

Question 3

What commonly causes CLI?

Answer 3

Atheroma
Vasculitis
Beurger’s

Question 4

What are the risk factors for CLI/ALI?

Answer 4

Male - Old - Smoker - Hypertension - Hypercholesterolaemia - Diabetes - History of CLI

Question 5

What are the symptoms of CLI?

Answer 5

Claudication
Rest Pain
Tissue Loss
Ulceration
Pallor
Hair Loss
Slow Capillary Refill
Reduced Pulses
Loss of peripheral sensation
Gangrene

Question 6

How can we investigate a case of CLI?

Answer 6

Duplex Ultrasound
CT angiography/MR angiography - First approach
Ankle/Brachial Pressure Index (ABPI)
Beurger’s Test

Question 7

What is the ABPI?

Answer 7

Ankle BP/Brachial BP

A value below 1 indicates loss of blood flow to lower limb

Question 8

What is the beurger’s test?

Answer 8

Unsurprisingly a test for beurger’s disease (occlusion of multiple medium & small arteries thanks to emboli)

Elevate legs - Pallor & severe ischaemic pain at any point below 20 degrees indicates beurger’s
Then hang feet over the bed - Should be slow to regain colour and turn a dark red colour due to hyperaemia

Question 9

Why do feet turn dark red in the beurger’s test?

Answer 9

Normally only 1/3 of capillaries are open.

However in CLI, autoregulation is lost and they all open and so your feet get hyperaemic.

Question 10

How do we treat varying levels of CLI?

Answer 10

A mild case gets Best Medical Treatment (BMT)
A severe case gets BMT & surgical bypass/angioplasty
A critical case adds endovascular reconstruction

Question 11

What is the Best Medical Treatment for CLI?

Answer 11

Antiplatelets
Statins
Anti-Hypertensives
Smoking Cessation
Exercise 
Diabetic Control

Question 12

What is ALI?

Answer 12

Sudden onset loss of blood flow to limb tissue due to stenosis/occlusion of peripheral arteries

Question 13

What causes ALI?

Answer 13

Mainly Thrombus in Situ or Arterial Embolus

Uncommonly Trauma, dissection or Acute Aneurysm Thrombosis

Question 14

What are the symptoms of ALI?

Answer 14

Sudden onset 6Ps:
Pallor - Pain - Perishing cold - Paresthesia - Paralysis - Pulseless
If possible compare to contralateral limb

Onset of Gangrene if left too long

Question 15

What is paresthesia?

Answer 15

Abnormal sensation

e.g. tingling, burning, tickling, numbness etc

Question 16

What kind of tests would you do for ALI?

Answer 16

ECG
Bloods
Creatine Kinase levels to indicate muscle damage
Check for myoglobulinuria before it causes renal failure

Question 17

What injury can occur after treating ALI?

Answer 17

Repurfusion injury which can lead to compartment syndrome

Question 18

What treatment can we give for ALI?

Answer 18

Analgesia
Anti-coagulants - heparin
Palliative Care
Embolectomy under GA/LA
Thrombolysis or Thrombectomy

Question 19

What is diabetic foot disease?

Answer 19

The high glucose levels of diabetes damage the endothelium (microvascular PAD) and sensation (peripheral Neuropathy) particularly in the feet.
This leads to easy development and missing of ulcers/infections

Question 20

What are the symptoms of Diabetic Foot Disease?

Answer 20

Ulcers
Bleeding
Swelling
Pus

Question 21

What particularly bad infections should be check for in Diabetic Foot disease?

Answer 21

Osteomyelitis (Bone infection/inflammation)
Gas Gangrene (Bacterial infection producing gas in tisses)
Necrotizing Fasciitis - Infection killing soft tissue

Question 22

How is diabetic foot disease prevented?

Answer 22

Always wearing shoes
Making sure they’re well fitted
Check pressure points on the foot regularly
Promptly treat any skin breaks

Question 23

How do we treat diabetic foot disease?

Answer 23

Wound Care
Systemic Antibiotics
Revascularisation (by distal bypas or distal crural angioplasty)

Question 24

What do we do if we fail to save the limb in any PAD?

Answer 24

Amputate that fucker,
Many spots to do it but Above knee (AKA) and below Knee (BKA) most common.
Also hindquarter, hip disarticulartion, through knee, symes (ankle), transmetatarsal and digit.

Question 25

How does rehab compare in AKA/BKA?

Answer 25

BKA gives better mobility and requires a lot less energy to walk after.

Question 26

What are the fontaine classes of PAD?

Answer 26

4 stages:

1) minor obstruction so asymptomatic
2a) Mild claudication >200m
2b) mild Claudication <200m
3) Foot pain at rest
4) Necrosis/Gangrene set in