Limb Ischaemia

Question 1

What is the definition of acute limb ischaemia?

Answer 1

Sudden decrease in limb arterial perfusion with an onset of < 2 weeks.

Question 2

Explain the presentation of acute limb ischaemia

Answer 2

6 P’s - Pulseless, painful, pale, paralysis, paresthesia, perishingly cold.
If the limb has lost motor and sensory function then likely unsalvageable

Question 3

What are the causes of acute limb ischaemia?

Answer 3

• Thrombo-embolism (most commonly caused by cardiac arrhythmias eg AF so get ECG),
• Aneurysms
• Trauma (eg, posterior knee dislocation)
• Dissection
• Thrombus of previous vascular reconstruction
• In situ thrombus in native vessels

Question 4

What is the management and treatment for acute limb ischaemia?

Answer 4

• Resuscitation, analgesia and catheter and doppler exam.
• Blood tests,
• ECG
• ABG
• CXR
• Anticoagulation with IV heparin
• CT Angiograph
• Restore blood supply (thrombolysis, surgery, angioplasty, bypass, amputation)

Question 5

Explain why a fasciotomy may be required in acute limb ischaemia?

Answer 5

when muscles are reperfused they can become oedematous which can cause compartment syndrome

Question 6

What are the patterns of disease seen in peripheral arterial disease?

Answer 6

• Intermittent claudication
• Critical limb ischaemia
• Acute limb threatening ischaemia

Question 7

What is intermittent claudication

Answer 7

Aching or burning pain in the leg muscles following walking. Relieved by rest

Question 8

What are the investigations for intermittent claudication?

Answer 8

Check pulses, check ankle-brachial pressure index, duplex ultrasound (first line of imaging) but must do MRA before intervention

Question 9

What is the management of peripheral arterial disease?

Answer 9

1. Atorvastatin 80mg
2. Clopidogrel
3. Exercise training and QUIT SMOKING
4. If severe then endovascular/surgical revascularization

Question 10

How can you determine whether a clot is a thrombus or emboli?

Answer 10

Thrombus - pre-existing claudication, no obvious source for emboli, reduced or absent pulse in contralateral limb, evidence of cv disease

Emboli - Sudden onset of painful leg, no history of claudication, obvious source of embolus, no evidence of PVD

Question 11

What is critical limb ischaemia?

Answer 11

Severe form of PAD which causes:
- Leg/foot pain at rest (burning or aching sensation at night)
- Non-healing wounds,
- Gangrene

Question 12

What is the inital management of acute limb threatening ischaemia?

Answer 12

Analgesia (IV opioids),
IV unfractionated heparin,
Vascular review

Question 13

What is the definitive management for acute limb threatening ischaemia?

Answer 13

Intra-arterial thrombolysis, surgical embolectomy, angioplasty, surgical bypass of amputation

Question 14

When is endovascular surgical revascularisation preferred to open?

Answer 14

Endovascular - short segments of stenosis(<10cm), aortic iliac disease and high risk patients.
Open - long segments of stenosis (>10cm), multifocal lesions, and lesions at the common femoral artery or intrapopliteal.

Question 15

What drug can be used in PAD?

Answer 15

Naftidrofuryl oxalate - vasodilator used in patients with poor QOL.