Limb Ischaemia

Question 1

Critical limb threatening ischaemia case

Answer 1

-Older
-Diabetic
-Ex smoker IHD
-Necrotic toe, Cellulitic with no abx improvement (misdiagnosis)
-Peripheral arterial disease (calf claudication)
-Swelling

-Absent femoral pulses, dorsalis pedis
-Buerger’s Test= positive (elevate foot turns white, dusky when down)

Question 2

Ankle Brachial Pressure Index

Answer 2

Highest measurements of upper limbs/ highest measurement lower limbs

CRT not useful

Question 3

Management in PAD

Answer 3

-Statin
-Aspirin/ clopidogrel
-Lower limb arterial duplex scan
-MRA (angiogram) to confirm duplex findings in 3D

=Amputation (necrotic= risk of severe foot infection in diabetic)
=Endarterectomy (need pulsatile inline flow, profunda revascularisation for claudication)
=Angioplasty/ stent (frail not fit for bypass)
=Artery bypass (fit for surgery, prosthetic if no vein)

Question 4

6 Ps in acute limb ischaemia

Answer 4

-Pain (not specific, marker of severity)
-Pulseless (compare, PAD)
-Paraesthesia (sensory nerve dysfunction)
-Paralysis (motor nerve dysfunction, most severe)
-Pallor (nail bed)
-Poikilothermia (cold, compare with other side)

Question 5

Management of severe acute limb ischaemia

Answer 5

-IV heparin bolus then infusion
-FBC, CK, coag, UE, CRP, Mg/Bone/LFT/TFT, group and save, lactate
-Analgesia, fluids

-CT angiogram: detailed info about all arteries, better in acute settings
-Surgical thrombo-embolectomy, amputation if not salvageable

Question 6

Malignancy and acute limb ischaemia

Answer 6

-Hyperviscosity= prothrombotic
-Arterial trashing= blue toe syndrome
=No surgery as pro-thrombotic, active bleeding so contraindicated thrombolysis

Arterial or venous thrombosis may be first presentation of malignancy