``` Ulceration Gangrene Calf pain at rest 15 secs ```

Chronic Limb Ischaemia Flashcards by Amrita Heer

Signs and symptoms

Ulceration
Gangrene
Calf pain at rest
<50mmHg at ankle
Absent femoral/popliteal/foot pulses
Atrophic skin
Punched out ulcers
Cold/pale legs
Bueger's Angle <20 degrees
Capillary Refill>15 secs

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What is Bueger’s Angle?

Angle that leg goes pale when raised off couch

Test for reactive hyperaemia if <20

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Phases of disease

Asymptomatic
Intermittent Claudication
Critical Limb Ischaemia
Gangrene/Ulcers

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Define intermittent claudication

Pain on exertion only
Relieved by rest
Typically in calves
Due to muscle not getting enough oxygen

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Define critical limb ischaemia

Extreme of intermittent claudication
Pain at rest >2 weeks
Presence of ischaemic lesions/gangrene
ABPI
Ankle pressure <50mmHg
Lose sensation then movement then pain

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Differentials for calf pain

Leriche's syndrome
Buerger's disease
Spinal stenosis
Venous claudication
Chronic compartment syndrome
Baker's cyst
Acute limb ischaemia

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Define Leriche’s syndrome

Buttock claudication with or without impotence

With leg pain

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Who gets Buerger’s disease?

Young heavy smokers

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How to distinguish with spinal stenosis?

Lower back pain radiating down lateral leg

Relieved by sitting/lying down for longer time

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How to distinguish with venous claudication?

Venous congestion & oedema
Worse in thigh/groin
Relieved by elevation

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How to distinguish with chronic compartment syndrome?

Tight burst calf pain after exercise in athletes

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How to distinguish with Baker’s cyst?

Pain in calf and behind knee at rest

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How to distinguish with acute limb ischaemia

Symptoms for <14 days

Sudden onset

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RF of chronic limb ischaemia

Smoking
DM
Dyslipidaemia
HTN

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Ix for chronic limb ischaemia

Buerger’s Test
ABPI
Duplex Doppler USS
MRI/CT

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ABPI

Ratio of systolic BP in lower leg to that in arms

ABPI<1 = lower BP in legs = peripheral arterial disease

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Use of ABPI

To diagnose peripheral arterial disease
In patients with leg ulcers
Can be harmful = further restricts blood supply to foot

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Interpretation of ABPI

>1.2 = calcified, stiff arteries, age, PAD
1-1.2 = normal
0.9-1 = acceptable
<0.9 = likely PAD
0.6-0.9 = claudication
0.3-0.6 = rest pain
<0.3 impeding

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Mild, moderate and severe PAD

Mild ABPI = 0.8-0.9
Moderate ABPI = 0.5-0.9
Severe = <0.5 = urgent referral

Duplex Doppler USS

Location and degree of stenosis

Stenosis >50% systolic velocity ratio

When to do a MRI/CT?

When considering intervention

Treatment Methods

Percutaneous Transluminal Angioplasty
Arterial Reconstruction Surgery - bypass
Limb Amputation

What is percutaneous transluminal angioplasty?

Catheter inserted into artery in groin/arm
Balloon inflated for a minute each time
Pushes fatty deposits
Preferred when patient has severe co-morbidities

Indications for percutaneous transluminal angioplasty?

Disease limited to single artery

Complications for PTA?

``` MI Arrhythmias Haemorrhage Wound infection Peripheral Oedema Thrombosis PE Bleeding at Catheter insertion sits Blood clot/damage to vessel Restenosis of vessel Nerve injury ```

What is arterial reconstruction surgery?

Vessel graft to divert blood flow from affected vessel Stitch on graft at place above and below damaged vessel Preserved for patients with critical limb ischaemia Use patient's own vein (autologous) - may have to reverse if valves or destroy valves Synthetic = PTFE (gortex)/Dacron = must use vein cuff to control turbulent flow at entry to vessel

Aorto-iliac disease

Stenosis >10cm Chronic occlusion >5cm Heavy calcified lesions

Common femoral artery disease

Lesions >10cm Heavy calcified lesion>5cm Lesion involving ostium of superficial femoral artery Lesion involving popliteal artery

Complications of femoral artery disease

``` Thrombosis Lower limb compartment syndrome Abdominal compartment syndrome Graft infections Pseudoaneurysms AV fistulae Aortoenteric fistulas ```

What is limb amputation?

Myodesis = shortening and smoothing out bone in remaining limb

Indications for limb amputation

Acute limb ischaemia - non viable limb | Chronic critical limb ischaemia - unsuitable for revascularisation

Rehabilitation post amputation

Day 1-2 = stump with bandage, wheelchair 3-5 = lie flat, straighten hip, exercise 6-10 = exercise 1-2x a day, stump shrinker compression sock, pneumatic post-amputation mobility aid to reduce stump swelling 10-21 = remove stitches, attend amputee rehab unit, offer prosthesis if appropriate

Pain control in palliative support

NSAIDs - ibuprofen Anticonvulsants - Carbamazepine/Gabapentin Antidepressants - amitriptyline Opoids - codeine/morphine Corticosteroid/Local anaesthetic injection

Common peripheral vascular issues

``` Arteries - occlusive disease - aneurysmal diseases - arterial dissection Veins - chronic venous insufficiency ```

What can happen after a plaque formation?

- aneurysm & rupture - occlusion by thrombus - critical stenosis

Define rest pain

Constant pain and need opiates | Normally at night

Medical Therapy to control RF

- diabetes control - reduce HbA1C by 1-21% - cholesterol = 80mg of atorvostatin for all! - BP control - antiplatelets = aspiring/clopidogrel 75mg for all tolerant! - anti-oxidants and vitamins = omega-3 fish oils

Benefits of angioplasty

Minimally invasive Short stay Quick recovery

Why are veins better for bypass?

Last longer than prosthetic grafts | Long saphenous better than umbilical

Risks of bypass

``` Graft failure MI Infections - esp prosthetics Limb loss Death ```

Benefits of bypass

Save limb Retain independence Wound healing

Who is eligible for bypass?

If going to be alive for >2 yrs = do bypass Otherwise angioplasty Aorto-iliac disease Common femoral artery disease

Allen's test

Occlusion of radial and ulnar arteries when fist is clenched | Colour return in 15 seconds when open hand if adequate arterial circulation = collateral

Indications for arterial reconstruction

Graft infection Thrombosis Lower Limb compartment syndrome

Indications for amputation

Tissue Loss | Claudication continuation despite bypass graft

How to complete a venous examination?

- DRE - abdomen exam - pelvic exam

Define lipodermatosclerosis

Inflammation of fat layer under epidermis