FN: Chronic limb ischaemia: Investigation and Management

Question 1

Investigations

Answer 1

Doppler Waveforms
ABPI
Walk test
Bloods
Imaging
Other: ECG ischaemic changes

Question 2

Doppler wave forms

Answer 2

Normal: triphasic
Mild stenosis: biphasic
Severe stenosis: monophasic

Question 3

Walk test

Answer 3

Walk on treadmill @ certain speed and incline to establish maximum claudication distance

ABPI measured before and after: 20% drop is significant

Question 4

Bloods

Answer 4

FBC, U+E: anaemia, renovascular disease
Lipds and glucose
ESR: arteritis
G+S: possible procedure

Question 5

Imaging:

Answer 5

Asses site, extent and distal run-off

1. Colour doppler US
2. CT/MRI angiogram: gadolinium contrast
3. Digital subtraction angiography
   - Invasive therefore not commonly used for Dx only
   - Used when performing therapeutic angioplasty or stenting

Question 6

Conservative Management

Answer 6

1. Most patients with claudication can be managed consrevatively
2. incerase excercise and emply excercise programs
3. Stop smoking
4. wt. loss
5. Foot care

Question 7

Prognosis of conservative management

Answer 7

1/3 improve
1/3 stay the same
1/3 deteriorate

Question 8

Medical Management

Answer 8

1. Risk factors: BP, lipids, DM: note B-blockers dont worsen intermittant claudication but use with caution in chronic limb ischaemic
2. Antiplatelts: aspirin/clopidgrel
3. Analgesia: may need opiates
4. (parentral prostanoids reduce pain in patients, unfit for surgery)

Question 9

endovascular Mx

Answer 9

1. Percutaneous transluminal angioplasty ± stenting
2. Good for short stenosis in big vessels e.g. iliac, SFA
3. Lower risk for pt: performed under LA as day case
4. Improved inflow and reduced pain but restoration of foot pulses is required for Rx of ulceration/gangrene

Question 10

Surgery indications

Answer 10

1. v. short claudication distance

Question 11

Pre op assesment

Answer 11

Need good optimisation as likely to have cardioresp co-morbidities

Question 12

Practicalitis

Answer 12

Need good proximal supply and distal run-off
Saphenous vein grafts preferred below th eIL
More distal grafts have increase rates of thrombosis

Question 13

Classifcation

Answer 13

Anatomical: fem-pop, fem-distal, aortobifemoral

Extra-anatomical: axillo-fem/bifem,fem-fem crossover

Question 14

Other

Answer 14

Endarterectomy: core-out atheromatous plaque
Sympathectomy: chemical (EtOH injectino) or surgical: caution in DM neuropathy
Amputation

Question 15

Prognosis 1 yr after onset of CLI

Answer 15

50% alive w/o amputation
25% will have had major amputation
25% dead (usually MI or stroke)

Question 16

Following amputation prognosis

Answer 16

Perioperative mortality
BL=K:5-10%
AK: 15-20%

1/3 completed autonomy
1/3 partial autonomy
1.3 dead