Arterial Limb Disease Flashcards
What are the 3 types of Arterial Limb Disease (Peripheral Arterial Disease)?
Critical Limb Ischaemia (CLI)
Acute Limb Ischaemia (ALI)
Diabetic Foot Disease
What is CLI?
Long term loss of blood flow to limb tissue due to stenosis/occlusion of peripheral arteries
What commonly causes CLI?
Atheroma
Vasculitis
Beurger’s
What are the risk factors for CLI/ALI?
Male - Old - Smoker - Hypertension - Hypercholesterolaemia - Diabetes - History of CLI
What are the symptoms of CLI?
Claudication Rest Pain Tissue Loss Ulceration Pallor Hair Loss Slow Capillary Refill Reduced Pulses Loss of peripheral sensation Gangrene
How can we investigate a case of CLI?
Duplex Ultrasound
CT angiography/MR angiography - First approach
Ankle/Brachial Pressure Index (ABPI)
Beurger’s Test
What is the ABPI?
Ankle BP/Brachial BP
A value below 1 indicates loss of blood flow to lower limb
What is the beurger’s test?
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
Why do feet turn dark red in the beurger’s test?
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 varying levels of CLI?
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?
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?
Mainly Thrombus in Situ or Arterial Embolus
Uncommonly Trauma, dissection or Acute Aneurysm Thrombosis
What are the symptoms of ALI?
Sudden onset 6Ps:
Pallor - Pain - Perishing cold - Paresthesia - Paralysis - Pulseless
If possible compare to contralateral limb
Onset of Gangrene if left too long
What is paresthesia?
Abnormal sensation
e.g. tingling, burning, tickling, numbness etc
What kind of tests would you do for ALI?
ECG
Bloods
Creatine Kinase levels to indicate muscle damage
Check for myoglobulinuria before it causes renal failure
What injury can occur after treating ALI?
Repurfusion injury which can lead to compartment syndrome
What treatment can we give for ALI?
Analgesia Anti-coagulants - heparin Palliative Care Embolectomy under GA/LA Thrombolysis or Thrombectomy
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 missing of ulcers/infections
What are the symptoms of Diabetic Foot Disease?
Ulcers
Bleeding
Swelling
Pus
What particularly bad infections should be check for 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?
Always wearing shoes
Making sure they’re well fitted
Check pressure points on the foot regularly
Promptly treat any skin breaks
How do we treat diabetic foot disease?
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 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.
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
