PAD Flashcards
how long until tissue necrosis occurs in acute limb ischaemia?
6 hours
common sites for Sx of arterial disease pain?
- COMMONEST: upper 2/3 calf (superficial femoral artery)
- buttock/hip (aortic and iliac artery)
- thigh (iliac or common femoral)
- lower 1/3 calf (popliteal)
- foot (tibial/peroneal)
define intermittent claudication?
predictable, reproducible pain on exertion caused by ischaemia of the muscle relieved by rest \+/- limp (10-30 percent have classic IC)
when taking a history of intermittent claudication?
ask: • how many yards they can walk • before they have to stop because of the pain • on the flat • at a normal pace • on their best day?
- patient comes in with *rest pain in the feet and toes (not calves)
- worse burning pain *at night *relieved by hanging legs over the side of the bed
- swollen, red leg
- unrelieved by medication for >2 weeks
- +/- evidence of tissue loss (*ulcer, *gangrene)?
critical limb ischaemia
*cardinal Sx
when could there be painless CLI?
DM (neuropathy)
classification used for PAD?
Fontaine:
1) Asx
2) IC (2a if stop >200m, 2b <200m)
3) Rest/nocturnal pain
4) Necrosis/gangrene
Sx - the 6 Ps of acute limb ischaemia?
Ex?
Pain at rest Pulseless Pallor Paraesthesia Perishingly cold Paralysis (late feature; irreversible damage)
Ex :
- if sudden (emboli from AF, mural thrombus, aneurysms) bruit may be heard
- fixed mottling indicated irreversibility
- may appear a deep dusky colour if acute on chronic in PAD, due to collaterals
ΔΔ leg pain?
MSK
• OA
Vascular
• PVD
• DVT
Neurospinal
• Disc degeneration
• Spinal stenosis
Neuropathic
• DM
• Alcoholic neuropathy
Infectious/inflammatory
• Cellulitis
• Arteritis
Ix PAD?
Bedside:
• ABPI via doppler US (**diagnostic if <0.9)
• ECG + BP (for CVS risk, cardiac ischaemia)
• Swab (ΔΔ cellulitis)
Bloods: • Lipids (dyslipidaemia) • Glucose (ΔΔ DM, CVS risk) • ESR/CRP (ΔΔ arteritis) • FBC (anaemia, polycythaemia) • U&E (renal disease) • Thrombophilia screen and serum homocysteine if <50 yrs (hyperhomocysteinemia)
Imaging:
• 1st line Duplex US (determines site of disease)
• Angiography (if surgery considered)
- MR angio if available
- CT angio better for wall abnormalities (aneurysms) but nephropathy and radiation
- intra-arterial digital subtraction angiogram (invasive) which allows Tx
diagnostic Ix for PAD?
ABPI (ankle-brachial pressure index)
• ratio of SBP at ankle and arm, taken after 10 mins at rest, using the highest measurements
ABPI in…?
1) claudication
2) CLI
3) impending gangrene
4) normal?
1) 0.5 - 0.9
2) <0.5
3) <0.3
4) 1-1.2
which is the GOLD standard imaging Ix for PAD that also allows Tx?
intra-arterial digital subtraction angiogram
invasive
risks of intra-arterial digital subtraction angiogram (invasive)?
thrombus embolisation
+/- vessel puncture
1/100 limb loss
Tx PAD?
Conservative:
• Advise exercise rehab (collateral blood flow)
• Foot care
• Quit smoking
Medical
• Clopidogrel 1st line (CVD risk)
• Naftidrofuryl (vasoactive drug, for those who cannot undergo surgery)
• Anti-hypertensives + statins
Surgical revascularisation
• Bypass (saphenous vein, or synthetic vessel)
• Endarterectomy
• Percutaneous transluminal radiological angioplasty + stenting (best if large like iliac, and only in single arterial segment)
• Amputation (last resort, in ulceration or gangrene)
