Arterial Limb Disease

Question 1

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

Answer 1

Chronic limb ischemia
Critical Limb Ischaemia (CLI)
Acute Limb Ischaemia (ALI)
Diabetic Foot Disease

Question 2

What is Chronic Limb ischemia? [2]

Answer 2

Long term loss of blood flow to limb tissue [1] due to stenosis/occlusion of peripheral arteries [1]

Question 3

What commonly causes CLI? [3]

Answer 3

Atheroma

Vasculitis eg Beurger’s

Question 4

What are the risk factors for CLI/ALI? [7]

Answer 4

Male - Old - Smoker - Hypertension - Hypercholesterolaemia - Diabetes
Hyperchromocysteinemia

Question 5

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]

Answer 5

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

Question 6

How can we investigate a case of CLI? [4]

Answer 6

Ankle/Brachial Pressure Index (ABPI)
Beurger’s Test
Duplex Ultrasound
CT angiography/MR angiography (if revasc considered)

Question 7

What is the ABPI? What is abnormal?

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? [3]

Answer 8

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]

Question 9

Why do feet turn dark red in the beurger’s test? [2]

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:

Mild, severe, critical

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? [6]

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? [4]

Answer 13

Mainly Thrombus in Situ or Arterial Embolus
Uncommonly 
Trauma
Dissection
Acute Aneurysm Thrombosis

Question 14

What are the symptoms of ALI? [6]

Outcome if untreated [1]

Answer 14

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

Onset of Gangrene if untreated

Question 15

What kind of tests would you do for ALI? [5]

Answer 15

1. urgent ABPI or duplex USS, angiography if incomplete occlusion
2. FBC, group and save, U&E, INR
3. ECG, CXR
4. Creatine Kinase levels to indicate muscle damage
   5, Check for myoglobulinuria before it causes renal failure

Question 16

What injury can occur after treating ALI? [2]

Answer 16

Repurfusion injury which can lead to compartment syndrome

Question 17

What treatment can we give for ALI? [5]

Answer 17

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

Question 18

What is diabetic foot disease?

Answer 18

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

Question 19

What particularly bad infections should we exclude in Diabetic Foot disease?

Answer 19

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

Question 20

How is diabetic foot disease prevented? [2]

Answer 20

Good foot care

Promptly treat any skin breaks

Question 21

How do we treat diabetic foot disease? [3]

Answer 21

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

Question 22

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

Answer 22

Amputate - AKA, BKA

Question 23

How does rehab compare in AKA/BKA?

Answer 23

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

Question 24

What are the fontaine classes of PAD?

Answer 24

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