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Cardiovascular System > Chronic Limb Ischaemia, Acute Limb Ischaemia, Diabetic Foot Disease, & Varicose Veins (pathology) > Flashcards

Chronic Limb Ischaemia, Acute Limb Ischaemia, Diabetic Foot Disease, & Varicose Veins (pathology) Flashcards

1
Q

What is chronic limb ischaemia? (Pathology)

A

Atherosclerotic disease of arteries supplying lower limb (less commonly vasculitis, Buerger’s disease)

Symptoms lasting greater than 2 weeks

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2
Q

What is critical limb ischaemia?

A

tissue loss, ulceration

  • due to minimal blood flow following years of atherosclerosis
    • rest pain/necrosis/gangrene
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3
Q

What are the risk factors for chronic limb ischaemia (6)?

A
  • Male
  • Age
  • Hypertension
  • Hypercholesterolaemia
  • Diabetes mellitus
  • Obesity
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4
Q

What are the 4 stages of the Fontaine classification of symptoms for chronic limb ischaemia?

A
  • Stage I: asymptomatic, incomplete blood vessel obstruction
  • Stage II: mild claudication pain
    • Stage IIA: claudication when walking > 200 m
    • Stage IIB: claudication when walking < 200 m
  • Stage III: rest pain, esp. feet
  • Stage IV: necrosis &/or gangrene of limb

(Stage III & IV) = critical limb ischaemia

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5
Q

What is claudication? What relieves this pain?

A

Pain described as dull or cramping - worse at night

- symptoms relieved by hanging legs off the side of the bed

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6
Q

What are the visible signs of chronic limb ischaemia?(5)

A
  • Ulceration
  • Pallor
  • Hair loss
  • Cold legs – Poikilothermia
  • Reduced/absent pulses
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7
Q

What are the signs you can feel of chronic limb ischaemia?

A

Peripheral:

  • Temperature
  • Capillary refill time
  • Peripheral sensation
  • Pulses (start at aorta)
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8
Q

What can be auscultated in chronic limb ischaemia?

A

AUSCULTATE with hand held doppler —> dorsal pedis and posterior tibial

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9
Q

What examinations can be performed to identify chronic limb ischaemia (2)?

A

1) Ankle Brachial Pressure Index (ABPI)
- symptom free ≥ 1
- intermittent claudication 0.95-0.5
- rest pain 0.5-0.3
- gangrene/ ulceration < 0.2
2) Buerger’s test
- Elevate legs -> develop pallor
- If limb goes pale at angle < 20= Buerger’s angle= severe ischaemia
- Hang feet over edge of bed
- Slow to regain colour &/or dark red colour- Hyperaemic sunset foot= all capillaries open

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10
Q

What imaging can be used to identify chronic limb ischaemia?

A 
-	Duplex scan 
	•	No radiation/contrast 
	•	Not good in abdomen 
-	CTA/MRA- FIRST LINE 
	•	Contrast/radiation
	•	Can overestimate calcification/difficult in low flow states (HF)
-	Digital subtraction angiography 
	•	Invasive- followed by angioplasty
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11
Q

What medical and risk factor control can be used to treat/management can be used to treat chronic limb ischaemia?

A 
Medical: 
-	Antiplatelet+ statins 
Risk factor control:
-	BP control < 140/85
-	Smoking cessation 
-	Diabetes control 
-	EXERCISE!!
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12
Q

What revascularisation therapies can be used to treat chronic limb ischaemia (2)? (Which is better)

A
  • Open surgery:
    • Bypass
    • Endarterectomy (open artery-> remove plaque)
  • Endovascular intervention:
    • Balloon angioplasty
    • Stent placement
    • Atherectomy (insert catheter-> remove plaque)

Superiority of open surgery over endovascular intervention (if short term morbidity is no issue - greater complications with open surgery)

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13
Q

What is acute limb ischaemia? How urgent is situation?

A

Sudden decrease in arterial blood flow to a limb that threatens its viability

MEDICAL EMERGENCY-> 6 hours to get to surgery
- if nothing done= amputation or death

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14
Q

What is the pathophysiology of acute limb ischaemia (5)? How long have symptoms lasted?

A
  • Arterial embolus- MI, AF, proximal atherosclerosis- NOT DVT, PE
  • Thrombosis of previously diseased artery
  • Trauma
  • Dissection
  • Acute aneurysm thrombosis (for example of popliteal artery)

Symptoms last <=2 weeks

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15
Q

What are the risk factors for acute limb ischaemia?

A
  • Cardiac history
  • History of chronic limb ischaemia
  • Risk factors for CLI
  • Functional status
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16
Q

What are the symptoms of acute limb ischaemia (6)?

A 
The 6 Ps:
-	Paralysis 
-	Paraesthesia 
-	Poikilothermia 
-	Pain 
-	Pulselessness 
-	Pallor
(When compared to the contralateral limb)
17
Q

What are the complications of acute limb ischaemia (2)?

A 
-	Compartment syndrome 
	•	Muscle ischaemia – irreversible > 6-8 h
	•	Inflammation
	•	Oedema 
	•	Venous obstruction 
	•	Tender calf 
	•	↑ Creatine kinase 
-	risk of kidney failure
18
Q

What is the treatment/management of acute limb ischaemia?

A
  • Salvageable limb + only embolus= Embolectomy
  • Salvageable limb+ thrombus in situ EITHER Thrombectomy/Thrombolysis OR Open embolectomy +/- bypass
  • Limb not salvageable EITHER Palliation OR Amputation (depending on patient’s fitness/ wishes)
19
Q

What is diabetic foot disease?

A

Microvascular peripheral artery disease characterised by FOOT ULCERS over bone prominences

20
Q

What % of diabetic patients are affected with diabetic foot disease? What % of ulcers become infected? what % need amputated?

A
  • 25% of diabetic patients affected
  • 50% of ulcers become infected
  • 20% of them need amputation
21
Q

What are the risk factors for diabetic foot disease?

A
  • Diabetes
  • Infection
  • Poor wound care
  • Not wearing shoes
  • Trauma
  • Foot deformity
22
Q

What preventative measures can be taken to avoid diabetic foot disease (7)?

A
  • Wear shoes
  • Check fit of footwear
  • Check pressure points/ plantar surface regularly
  • Prompt and regular wound care
  • Glycaemic control
  • Systemic antibiotics if infection
  • Investigate for osteomyelitis, gas gangrene, necrotising fasciitis
23
Q

Which adjunctive measures can be taken to minimise risk of diabetic foot disease (3)?

A
  • Dressings
  • Debridement - larval therapy
  • Negative pressure wound closure – vacuum pump - ve pressure applied—> ↑ granulation
24
Q

What is the management of diabetic Foot disease?

A
  • Revascularisation (very distal disease)
    • Distal crural (about leg/thigh) angioplasty
    • Distal bypass
  • Amputation —> Above or below knee
    ↑ energy for AKA

Cardiovascular System (37 decks)

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