claudication of the lower limb Flashcards
what is peripheral arterial disease? PAD
a chronic atherothrombotic occlusive disorder of the peripheral circulation that predominantly affects the large, medium-sized and small arteries of the lower limbs
risk factors for PAD
age over 55 years smoking, diabetes mellitus hypercholesterolaemia hypertension obesity sedentary lifestyle
how do patients with PAD present
intermittent claudication IC
critical limb ischaemia CLI
patients with CLI present with these signs
ankle pressures < 50mmhg
toe pressures < 30mmhg
ischaemic pain at rest
tissue necrosis - gangrene or ulcer
3 clinical categories for PAD
aorto iliac disease
femoral popliteal disease
tibio peroneal disease
what is intermittent claudication
IC is defined as an exertional symptom affecting muscles of the lower limb secondary to PAD
how is claudication classified
intermitten claudication associated with PAD
spinal claudication
venous claudication
atypical claudication
what do patients complain of with PAD
pain lameness discomfort cramping stiffness ipsilateral calf muscles stiff rarely thigh muscles and buttocks
what is leriche syndrome
aorto iliac disease
impotence
buttock claudication
how do patients with IC present vs spinal claudication, venous claudication
IC: claudication on walking esp on inclines, relief from 3-5 minutes of rest standing
spinal claudication: often associated with spinal stenosis, Difficulty getting up; long claudication distances; improvement with walking on incline, relief from rest lying down or sitting for 20-30min
venous claudication: associated with venous reflux and occlusive disease
risk factors for IC
smoking risk increased 4x
diabetic patients risk 2x increased
how do you predict progressive IC
ankle brachial index = ratio of ankle pressure/ brachial blood pressure = < 0.50
ddx of painful lower limb
Spinal stenosis
Sciatica
Lumbar spondylosis
Arthropathy (osteo, rheumatoid, gout, etc.)
Varicose veins
Deep-vein thrombosis/post-phlebitic syndrome
Peripheral neuropathy (diabetic, alcohol- associated, etc.)
Chronic regional pain syndromes
Chronic exertional syndromes (anterior compartment syndrome, etc.)
Restless leg syndrome
Infections (cellulitis, tinea pedis, etc.)
Other vascular pathologies (popliteal aneurysms, iliac artery syndrome of the cyclist, etc.)
what is the baseline evaluation of the claudicant
Full blood count
Fasting lipid profile
Fasting blood glucose/HbA1C (glycosylated haemoglobin)
Serum urea, creatinine and electrolytes
Blood clotting profile

Additional tests to be based on clinical suspicion, e.g. a thrombophilia profile in young patients with PAD
furhter investigations for PAD
lower limb exercise doppler test duplex doppler arteriography multi detector computed tomography magnetic resonance angiography peripheral angiography
what is the exercise doppler test for
ABI can be calculated
- after 10 minutes at rest
- after exercise 3.2kph on incline of 10 degrees for 5 minutes
what is the ABI for patients with IC and how does it chnage with exercise testing
0.5-0.9
drops by 15-20% with exercise
life style modifications needed for pt with IC and PAD
weight loss
diet
exercise
smoking cessation
pharmacological interventions for IC and PAD
optimisation of blood pressure
diabetic glucose control
antiplatelet therapy
lipid-lowering agents.
conservative management of IC PAD
smoking cessation:theraoy, nicotine replacement, buproprion = antidepressant
exercise therapy: walking 30min 3 times a week
pharmacotherapy in management of IC PAD
cilostazol
naftidrofuryl
MOA, SE, DOSE of cilostazol
MOA:phospodiesterase type III inhibitor with vasodilating, metabolic and antiplatelet properties
dose:50 - 100 mg twice daily
SE:headache, diarrhoea and palpitations. It should not be used in patients with congestive cardiac failure.
MOA and dose of naftidrofuryl
moa: 5- hydroxytryptamine type II inhibitor that improves muscle metabolism and prevents red-cell and platelet aggregation
dose: 600mg daily
which patients need revascularisation?
lifestyle limiting
medically refractory severe or progressive claudication
Younger patients with occupationally disabling claudication and aorto-iliac (large-vessel) disease
