Case 21: Limb Problems Flashcards
what is an aneurysm
a dilation of an artery which is bound by all 3 walls of the vessel
what is a pseudoaneurysm
bleed from an artery which pools in an enclosed space next to the vessel
what is a dissection
the intima tears and blood enters, separating it from the media and creates a false lumen which can become aneurysmal and/or lead to reduction of distal blood flow
most common artery affected by aneurysm
AA
most common artery of the leg to be affected
popliteal
typical presentation of popliteal aneurysm
easy palpable popliteal
may have co-morbid abdominal aneurysm
complications of popliteal aneurysm
more likely to cause thrombosis rather than rupture- leads to acute limb ischaemia
management of popliteal aneurysm
for acute ischaemia- femoropopliteal bypass
is discovered before thrombosis- graft
what is an ulcer
a discontinuity of skin with complete break in the epidermis and possibly dermis and subcutaneous tissue
what is an erosion
a partial break in epidermis, appears bright red and weepy
causes of ulcers
trauma and/or internal pathology
types of ulcers
arterial
venous
vasculitis
neuropathic
what is the most common cause of neuropathic ulcers
diabetic foot
how to investigate causes of ulcers
ABPI for arterial disease
urine glucose for diabetes
test skin sensation and vibration is suspected neuropathic ulcer
doppler US for venous insufficiency
FBC, Us and Es and ESR may show signs of vasculitis, infection or arterial disease
management of ulcers
treat underlying cause- PVD, diabetes, vasculitis
are venous or arterial ulcers more common
venous
venous= 2/3
arterial= 1/3
pathophysiology of venous ulcers
venous insufficiency can cause fluid to leak from veins and capillaries leading to oedema and deposition of plasma proteins, including fibrinogen and inflammatory mediators
this leads to hypoxia, damage to local tissues and eventually ulceration
commonest cause of venous ulcers
incompetence of perforator veins
what does a venous ulcer look like
rough edge
redness
typical location of venous ulcer
medial leg along great saphenous vein
what may you see on surrounding skin of venous ulcer
purple/blue skin (blood) and/or brown (hemosiderin)
varicose veins
lipodermatosclerosis (inflammation of the subcutenaous fat causing pain and constriction of the soft tissue)
venous eczema (crust and weepy)
hot
management of venous ulcer
if slough is affecting healing can use desloughing dressing (iodine dressing)
usually use non-adherent dressing
surround with compression bandaging to squeeze fluid out over days, then compression stockings long term
elevation helps fluid drainage
antibiotics if signs of infection
management for venous ulcer with superficial vein incompetence
surgery (junction disconnection, stripping and avulsion) or endogenous ablation
this is not suitable post-DVT
how to manage venous eczema
betnovate (betamethasone)
pathophysiology of arterial ulcers
caused by chronic peripheral vascular disease
risk factors for arterial ulcers
diabetes
smoking
what do arterial ulcers look like
punched out appearance
Clear edge
common places for arterial ulcers
distal pressure points- toes, pads, heels, maelloli
what may be surrounding skin of arterial ulcers be like
pale
painful
cool
shiny
hairless
weak/absent pulse
signs of infection
appearance of vasculitis ulcers
vessel destruction initially leads to purpura then necrosis (black/green/yellow areas)
ulcers with a blue/purple edge then appear after a few days
what bacteria causes gangrene
Clostridium perfringens (releases alpha toxin)
how do you typically get gangrene
the bacteria inhabit the soil or normal gut flora
enters in major trauma/GI surgery
rarely is non-traumatic due to colorectal carcinoma or immunosupression
gangrene signs and symptoms
pain (may be sudden onset and out of proportion to symptoms)
skin crepitus crackly on palpation
skin becomes dark purple, swollen and bullae form
septic shock
gangrene management
surgical debridement
Iv antibiotics
what causes PVD
atherosclerosis of peripheral arteries
what limbs are most commonly affected by PVD
legs most commonly but can also affect arms
when does acute limb ischaemia progress to necrosis
within 6 hrs if untreated
commonest site affected by chronic PVD
the upper 2/3 of calf due to superficial femoral artery
2nd commonest site affected by chronic PVD
buttock and hip due to aortic and iliac artery
other sites affected by chronic PVD
thigh (iliac or common femoral artery)
lower 1/3rd of calf (popliteal artery)
foot (tibial or perineal artery)
what is claudication
predictable, reproducible pain on exertion causes by ischaemia of the muscle which is relieved by rest
predictable, reproducible pain on exertion causes by ischaemia of the muscle which is relieved by rest
30%
Qs to ask to assess claudication severity
how many yards can walk before having to stop due to pain, on flat at normal pace on their best day
definition of critical limb ischaemia
rest pain, unrelieved by medication for 2 or more weeks and/or evidence of tissue loss (ulcer/gangrene)
other features of critical limb ischaemia
pain may be absent due to neuropathy
pain in feet and toes
pain worse at night due to reduced gravitational pull
swollen leg (may also be red from metabolite-triggered capillary dilation)
fontaine classification
is for chronic limb ischaemia
1= asymptomatic
2= intermittent claudication (2a if stops over 200m, 2b if less than 200m)
3= rest/nocturnal pain
4= necrosis/gangrene
acute limb ischaemia 6 Ps
pain at rest
pulseless
pale
paraesthesia
perishingly cold
paralysis (late feature suggesting irreversible damage)
ABPI results
<0.9 is claudication
<0.6 is rest pain
<0.3 is gangrene
management of PVD
active- rehabilitation programmes
CVD prevention
clopidogrel= 1st line antiplatelet
naftidrofuryl (vasodilator) can increase walking distance
management of acute limb ischaemia
heparin IV then embolectomy with Fogarty catheter
thrombolysis with alteplase if not surgically fit
when would you consider amputation
ulceration and gangrene
what are varicose veins
tortuous dilated superficial veins usually in the legs
what is the usually cause of varicose veins
incompetent valves
vein affected when there are varicose veins along medial leg
sapheno-femoral function of the long saphenous vein
vein affected when there are varicose veins along lateral calf
sapheno-popliteal junction of the short saphenous vein
vein affected when there are varicose veins along medial calf
perforator veins
RFs for varicose veins
family history
prolonged standing
abdominal or pelvic masses compressing IVC or iliac veins (pregnancy, obesity)
investigation for varicose veins
doppler US
conservative management of varicose veins
compression therapy (stockings or graded compression bandaging)
weight loss
avoid prolonged standing
simple analgesia if pain
surgical management of varicose veins
indicated if pain or ulceration
SFJ ligation and vein stripping, stab avulsions, radiofrequency or laser ablation, injection of sclerosing foam
what medication must you stop before varicose vein surgery
must stop oral contraceptive pill 4-6 weeks pre-op due to DVT risk
modifiable risk factors for atherosclerosis
T2D
obesity
hypertension
hypercholesterolaemia
physical inactivity
smoking
non-modifiable risk factors for atherosclerosis
T1D
family history
age
sex
renal effects of atherosclerosis
hypertensive nephropathy
hypertension resistant to medical treatment
cerebrovascular effects of atherosclerosis
TIA
stroke
amaurosis fugax
drop attacks
peripheral vascular effects of atherosclerosis
intermittent claudication
gangrene
arterial foot ulcer
ischaemia rest pain
coronary artery of atherosclerosis
angina
ACS
mesenteric artery effects of atherosclerosis
post-prandial abdominal pain
weight loss
hypertension resistant to medical management
what is amaurosis fugax
transient unilateral loss of vision
often described as ‘a curtain falling’ over their vision
due to emboli passing into the ophthalmic artery, which is usually from a stenosis in the ipsilateral carotid artery
what are drop attacks
sudden episodes of dizziness or syncope
what is sunset foot
do buergers test
affected leg is raised and held up for a while
turns white and cold- may indicate chronic arterial stenosis of the lower extremity
putting the leg down would resume blood flow to the foot under the effect of gravity, therefore the leg would regain its red discoloration
this is called sunset foot sign
features of neuropathic ulcers
deep in depth
pink wound bed
small in size
thickened/raised edge
features of arterial ulcers
sunset foot
small sized
punched out
distal location
black tissue
features of venous ulcers
thickened skin
pink wound bed
irregular edge
shallow wound
gaiter
varicose veins
potential changes to the appearance of the limbs in chronic venous insufficiency
erythema
ulceration
oedema
rash
brown skin (due to haemosiderin deposition)
thickened skin
potential symptoms of chronic venous insufficiency
night cramps
itching
aching
restless legs
pain
heaviness
pathophysiology of varicose veins
venous insufficiency can be due to failing of the valves in the veins of the legs
this means the veins aren’t able to stop blood falling down the leg
this means blood pools at the bottom of the legs, and the veins dilate to accommodate
more common in standing occupations and pregnancy
pain in leg when walking differentials
musculoskeletal= knee oestoarthritis
neurological= spinal canal stenosis
peripheral arterial= intermittent claudication
venous= chronic venous insufficiency
RFs for intermittent claudication
smoking
hypertension
male
family history of CVD
older age
red flag symptoms for the leg pain
rest pain- ischaemic rest pain warrants urgent referral to vascular
night pain
tissue loss
sudden onset symptoms associated with sensorimotor deficit- indicative of acute limb ischaemia and is a medical emergency
leg swelling- suggests DVT and needs duplex US to rule out
typical findings of intermittent claudication in right leg
right foot paler and cooler than the left
with a delayed capillary refill
on left femoral, popliteal, posterior tibial and dorsalis pedis pulses were palpable, but on the right only femoral
no evidence of tissue loss
what actually causes the pain in intermittent claudication
the muscles have increased O2 demands during exercise which cannot be delivered due to the muscles compromised blood supply
muscles most commonly affected are in calf due to femoral-popliteal vessels being affected
which exercise most commonly brings on intermittent claudication pain
walking (especially uphill)
what is atherosclerosis
hardening and narrowing of the arteries due to plaque (most commonly lipid)
symptoms of atherosclerosis in the coronary arteries
vomting
anxiety
angina
coughing
syncope/pre-syncope
(can lead to MI)
symptoms of atherosclerosis in the carotid arteries
weakness
headaches
facial numbness
paralysis
(can lead to stroke)
symptoms of atherosclerosis in the kidneys
reduced appetite
hand/feet swelling
increased BP
how can atherosclerosis cause a thrombus
the plaque ruptures
causes coagulation to stop the contents spilling out into he blood
this creates a thrombus (this can go on to impede blood flow)
there is increase in which type of cholesterol in atherosclerosis
LDL
what investigation would you do to distinguish between intermittent claudication and spinal canal stenosis
MRI
how is an ankle brachial pressure index (ABPI) performed
doppler auscultates the brachial
BP cuff is inflated until signal disappears
doppler then placed at posterior tibial/dorsalis pedis
BP cuff inflated (at ankle) until signal disappears
results of ABPI
the results are expressed as ratio (ankle:brachial)
if 1- leg and arm are the same so normal
if below 0.8- may have intermittent claudication (or no symptoms at all)
if below 0.4- might have pain at rest and/or at night and tissue loss (suggests chronic limb-threatening ischaemia)
when would you offer angioplasty and stenting for intermittent claudication
after modifiable risk factors have been reinforced
when supervised exercise programme has not lead to satisfactory improvement in symptoms
imaging has proved that angioplasty is suitable
which 2 medications should be commenced with intermittent claudication
an antiplatelet- aspirin/clopidogrel
statin (regardless of serum cholesterol levels)
how is angioplasty performed
needle punctures common femoral artery at groin level
contrast dye is injected into artery to visualise stenosis/occlusion
wire passed through diseased artery and ballon is passed over wire
it is inflated in the diseased segment with widen blood flow
what to do if angioplasty doesn’t work
can do bypass
incisions are made over the arteries above and below the disease
usually great saphenous vein is removed from the leg, reversed and stitched to the artery as an alternative conduct
does intermittent claudication progress to worse
1/3= symptoms resolve and unaffected
1/3= symptoms remain stable and do not progress
1/3= symptoms worsen (claudication distance decreases, lifestyle more impacted), can progress to critical limb ischaemia (rest and/or night pain)
what % of those with intermittent claudication have amputation
1%
