Chronic limb ischaemia Flashcards
Evidence of critical limb ischaemia?
tissue loss, ulcers, rest pain
Which test can illicit rest pain?
Beurger’s test. With the patient supine, elevate both legs to an angle of 45 degrees and hold for one to two minutes. Observe the color of the feet. Pallor indicates ischaemia. It occurs when the peripheral arterial pressure is inadequate to overcome the effects of gravity.
Order nerves, muscles, skin, in order of which is affected first due to arterial insufficiency?
skin>nerves>muscle (nerves are the most important)
What are the risk factors for chronic limb ischaemia?
smoking, diabetes, hypertension, hyperlipidaemia, old age (similar for acute limb ischaemia)
Name four symptoms/signs of chronic limb ischaemia
- Claudication
- Rest pain (worse at night)
- Arterial ulcer- painful
- Tissue loss
- Gangrene
How is chronic limb ischaemia diagnosed?
history, exam, arterial/brachial pressure index, angiogram, doppler ultrasound
What is the management of chronic ischaemia?
- Conservative: stop smoking, exercise, BP control, antiplatelet drugs
- Angiography, stent
- Surgical- bypass vessel above obstruction to vessel below
- Amputation
Which combination bypasses are typically performed in chronic limb ischaemia?
aorto-femoral, femoral-popliteal, axillo-femoral, femoral-femoral
What is the number one cause of chronic limb ischaemia?
atherosclerosis
Which is the most important bedside exam in assessing limb viability?
buerger’s test
Explain a positive buerger’s test
positive when foot rubor reduces with elevation and returns upon dependency. Cellultici foot will not blanch when elevated, therefore negative test for cellulitis
Which staging system is used to score chronic ischaemia?
rutherford classification, 6 stages for chronic while 4 stages for acute.
Chronic limb ischaemia rutherford stage 3. Is there serious tissue threat/loss?
stage 3= severe claudication. For acute, stage III would be complete loss of motor and sensory function
Acute ishaemic limb rutherford stage 3. What is the management for this?
amputation
What are complications of surgery?
Procedural: bleeding, infection, risk of worsening +amputation
Long term/general: respiratory compromise, MI, AKI, stroke
Specific: delayed healing
31 year old man with blue fingers and toes. He is a heavy smoker. What is the diagnosis?
thromboangiitis obliterans (also known as Buerger disease). The key presentation to remember for your exams is a young male smoker with painful blue fingertips. The exam question may ask the diagnosis or ask the most important aspect of management (completely stopping smoking).