Lower Extremity Atherosclerosis

Question 1

How do you treat blue toe syndrome?

Answer 1

Avoid anticoagulation since it may lead to dislodging of plaque. Use antiplatelets, statins, steroids.

Question 2

What’s a risk factor for blue toe syndrome?

Answer 2

Aortic plaque >4 mm thick or with ulceration

Question 3

What is Class I Acute Limb ischemia?

Answer 3

Viable, no sensory/motor loss, artery/venous signal present
Treat w Anticoag, intervene after acute phase over

Question 4

What is IIa ALI?

Answer 4

Marginally threatened, minimal sensory loss, no motor loss, artery signal loss, venous signal present
Treat with urgent intervention

Question 5

What is IIb ALI?

Answer 5

Immediately threatened.
rest pain, sensory loss more than toes, mild-moderate motor loss.
Artery signal loss, venous signal present
Treat w immediate intervention

Question 6

What is III ALI?

Answer 6

Irreversible.
Profound sensory/motor loss, loss of arterial/venous signal
Treat with amputation/palliation

Question 7

What’s outcome difference for bypass for ALI vs non-ALI?

Answer 7

~same graft patency (1y 18%), but ALI has higher major limb loss (22% vs 10%) and mortality (21% vs 13%)

Question 8

What’s dose/rate of tPA for lysis cath?Heparin for sheath?

Answer 8

2-4 mg initial bolus followed by 1mg/infusion.
Drop to 0.5 mg/h if fibrinogen <200, stop if <100
Heparin @ 500u/h in sheath

Question 9

What are major contraindication for tPA?

Answer 9

Active bleeding, GI bleed <10 days, CVA <6 months, cranial/spinal surgery <3 months, head injury <3 months

Question 10

What are relative contraindications for tPA?

Answer 10

surgery/trauma <10d, HTN (>180/110), CPR <10d, puncture of noncompressible vessel, intracranial tumor, pregnancy, diabetic hemorrhagic retinopathy, recent eye surgery, hepatic failure, bacterial endocartiditis

Question 11

What are outcomes of catheter directed thrombolysis vs open thrombectomy?

Answer 11

Similar limb salvage (~80%), but survival improved w CDT (58% vs 84%) mainly due to lower cardiopulm complications.

Question 12

What are absolute indications for fasciotomy?

Answer 12

Tense compartment + one of following:
- Pain with passive motion
- Paresis/parasthesia
- Unexaminable patient
- ICP-MAP < 40 mmHg
- ICP-Diastolic < 10 mmHg

Question 13

What length of fasciotomy incision has been shown to be adequate?

Answer 13

12-20 cm

Question 14

What is the diagnostic criteria for Chronic Exertional Compartment Syndrome?

Answer 14

Pain with nerve-specific paresthesia 20-30 minutes after exertion.

1 or more compartment pressure:
- Resting > 15 mmHg
- 1-2 minute post exercise: >30
- 5 min post exercise: >20

Treat w fasciectomy.

Question 15

What is the natural history of claudication

Answer 15

Over 5 years:
70-80% stable, 10-20% worsening, 1-2% CLTI