Arterial Occlusive Disease

Question 1

What is PAD?

Answer 1

Peripheral arterial disease

Occlusion of peripheral arteries leading to decreased blood supply to the legs

Question 2

What are risk factors?

Answer 2

Age
FH
Male
Obesity
Sedentary lifestyle
High fat intake
High alcohol intake 
Smoking
HTN
Hyperlipidaemia
Diabetes
RA

Question 3

What are the 3 main categories of PAD?

Answer 3

Intermittent claudication
Critical limb ischaemia
Acute life threatening limb ischaemia

Question 4

What is intermittent claudication?

Answer 4

Normally the first sign of PAD
Calf pain on exertion that is relieved by rest
Patients can work a predicted distance before the onset of pain

Question 5

What is critical limb ischaemia?

Answer 5

When symptoms are present at rest

Question 6

What is ABPI and what does it show?

Answer 6

Ankle Brachial Pressure Index

Helps to determine blood flow through the limbs

>1.2= calcification e.g. diabetes
0.9-1.2= normal
0.6-0.9= intermittent claudication
0.3-0.6= rest pain and critical limb ischaemia, ulcers
<0.3= severe disease- gangrene

Question 7

What are signs of PAD?

Answer 7

Limbs appear

• pale
• cyanotic
• muscle wasting
• hair loss
• decreased sensation
• decreased temperature
• increased CRT
• poor wound healing

Buergers Test +ve

• patient lies flat and slowly raise their legs to 45 degrees and hold for 1-2mins
• lower leg becomes pale
• then get patient to sit on side of bed with legs dangling down
• legs turn blue then dark red (rubor)

Question 8

What is the conservative management?

Answer 8

Lifestyle changes

• lose weight
• stop smoking
• reduce alcohol intake

Exercise programs
-walk until pain at worst then rest and repeat

Question 9

What is the medical management?

Answer 9

Atorvastatin 80mg od

Clopidogrel 75mg od

Question 10

What is the surgical managment?

Answer 10

Angioplasty
Stenting
Bypass

Can be done for critical limb ischaemia too

Question 11

How is critical limb ischaemia diagnosed?

Answer 11

At least one of the following

• rest pain present for >2wks
• ulcers
• gangrene

Question 12

What is acute life threatening limb ischaemia?

Answer 12

Sudden onset ischaemic limb

Question 13

What are the symptoms and signs of ALTLI?

Answer 13

Pale
Pulseless
Painful
Perishingly cold
Paraesthesia 
Paralysis

Question 14

What investigations are needed for ALTLI?

Answer 14

Doppler USS to find the affected vessel

ABPI afterwards

Question 15

What are the two main causes of ALTLI?

Answer 15

Thrombus

Embolus

Question 16

How can a thrombus cause be determined?

Answer 16

Pre existing claudication with sudden worsening
History of vascular disease
No obvious emboli source
Reduced or absent pulses in other limb

Question 17

How can an embolus cause be determined?

Answer 17

Sudden onset of symptoms <24hrs
No history of PAD
No history of vascular disease
Increased disposition to embolus e.g. AF
Evidence of proximal aneurysm

Question 18

What is the initial management of ALTLI?

Answer 18

Analgesia
Unfractionated heparin
Vascular review

Question 19

What is definitive management of ALTLI?

Answer 19

Intra arterial thrombolysis
Embolectomy
Angioplasty
Bypass
Amputation