Arterial Limb Disease Flashcards
What are the 3 types of Arterial Limb Disease (Peripheral Arterial Disease)? [3]
Chronic limb ischemia
Critical Limb Ischaemia (CLI)
Acute Limb Ischaemia (ALI)
Diabetic Foot Disease
What is Chronic Limb ischemia? [2]
Long term loss of blood flow to limb tissue [1] due to stenosis/occlusion of peripheral arteries [1]
What commonly causes CLI? [3]
Atheroma
Vasculitis eg Beurger’s
What are the risk factors for CLI/ALI? [7]
Male - Old - Smoker - Hypertension - Hypercholesterolaemia - Diabetes
Hyperchromocysteinemia
What are the symptoms of CLI? [3]
What are some signs you may see OE? [8]
What are signs that you would see in CRITICAL limb ischemia [3]
Intermittent claudication - Exertional - Cramp-like pain - location: buttock, thigh, calf Signs OE - Tissue Loss - Pallor, Hair Loss - Slow Capillary Refill Time - Reduced Pulses - Loss of peripheral sensation
Signs OE of critical limb ischemia
- Ulceration
- Gangrene
- Rest pain
How can we investigate a case of CLI? [4]
Ankle/Brachial Pressure Index (ABPI)
Beurger’s Test
Duplex Ultrasound
CT angiography/MR angiography (if revasc considered)
What is the ABPI? What is abnormal?
Ankle BP/Brachial BP
A value below 1 indicates loss of blood flow to lower limb
What is the Beurger’s test? [3]
Elevate legs - Pallor & severe ischaemic pain at any point below 20 degrees indicates beurger’s [1]
Then hang feet over the bed [1] - Should be slow to regain colour and turn a dark red colour due to hyperaemia [1]
Why do feet turn dark red in the beurger’s test? [2]
Normally only 1/3 of capillaries are open.
However in CLI, autoregulation is lost and they all open and so your feet get hyperaemic.
How do we treat:
Mild, severe, critical
A mild case gets Best Medical Treatment (BMT)
A severe case gets BMT & surgical bypass/angioplasty
A critical case adds endovascular reconstruction
What is the Best Medical Treatment for CLI? [6]
Antiplatelets Statins Anti-Hypertensives Smoking Cessation Exercise Diabetic Control
What is ALI?
Sudden onset loss of blood flow to limb tissue due to stenosis/occlusion of peripheral arteries
What causes ALI? [4]
Mainly Thrombus in Situ or Arterial Embolus Uncommonly Trauma Dissection Acute Aneurysm Thrombosis
What are the symptoms of ALI? [6]
Outcome if untreated [1]
Sudden onset 6Ps:
Pallor - Pain - Perishing cold - Paresthesia - Paralysis - Pulseless
If possible compare to contralateral limb
Onset of Gangrene if untreated
What kind of tests would you do for ALI? [5]
- urgent ABPI or duplex USS, angiography if incomplete occlusion
- FBC, group and save, U&E, INR
- ECG, CXR
- Creatine Kinase levels to indicate muscle damage
5, Check for myoglobulinuria before it causes renal failure
What injury can occur after treating ALI? [2]
Repurfusion injury which can lead to compartment syndrome
What treatment can we give for ALI? [5]
MORPHINE and METOCLOPRAMIDE Heparin followed by warfarin post-op
Surgery:
- Amputation if non-viable features
- Re-vascularisation for viable limbs:
1. Endovascular: perc. catheter directed thrombolytic therapy, thrombus extraction +/- thrombolysis
2. Open: thrombectomy/embolectomy, bypass, arterial repair
What is diabetic foot disease?
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 missed detection of ulcers/infections
What particularly bad infections should we exclude in Diabetic Foot disease?
Osteomyelitis (Bone infection/inflammation)
Gas Gangrene (Bacterial infection producing gas in tisses)
Necrotizing Fasciitis - Infection killing soft tissue
How is diabetic foot disease prevented? [2]
Good foot care
Promptly treat any skin breaks
How do we treat diabetic foot disease? [3]
Wound Care
Systemic Antibiotics
Revascularisation (by distal bypas or distal crural angioplasty)
What do we do if we fail to save the limb in any PAD?
Amputate - AKA, BKA
How does rehab compare in AKA/BKA?
BKA gives better mobility and requires a lot less energy to walk after.
What are the fontaine classes of PAD?
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
