PAD Flashcards
Definition of PAD
Chronic insufficiency of the arterial blood flow to the lower limb due to stenosis or occlusion of the vessels Primary cause is arthrosclerosis or fibromuscular dysphasia.
Symptoms of PAD classical presentation?
Intermittent claudication which is a muscular pain brought by exercise and reduced by rest
Critical limb Ischemia which is a rest pain For more than two weeks caused by the increased demand of oxygen by the muscles in context of reduce blood supply
Tissue loss Ulcers gangrene or necrosis
Pallor Of the lower limb
Reduced temperature in the lower limb
Tingling Or paraesthesia
What is Leriche syndrome?
It is an inclusion at The bifurcation of the aorta causing a classical triad;
Absent femoral pulses, erectile dysfunction, buttocks/thigh claudication
Rutherford-Fontaine classification ?
I Asymptomatic
II a ;Claudication distant more than 200 m / b;Claudication distant less than 200 m
III Rest pain
IV Tissue lossUlcers Gangrene and necrosis
Differential diagnosis of PAD?
Spinal stenosis
osteoarthritis
sciatica
Question to ask regards the history of PAD?
Where is the pain when did it start is it worse by movement how far can you walk before it you need to stop does the pain go away when you stop does the pain even occur at rest, at night , relieved by hanging the of over the bed Noticed any color change or temperature any soreness or black area in the lake do you smoke do you have a high cholesterol do you have diabetes do you have any hypertension what age are you
Risk factors of PAD?
None Modifiable risk factors such as age>55 , FHx vascular disease Smoking hypertension diabetes previous stroke/MI high cholesterol level Hyperhomocystinemia
Investigation of PAD?
Exclude diabetes , Arthritis ESR/CRP full blood count for anemia U&E lipids ECG Thrombophilia screen Ankle- Brachial pressure Index : Normal is 1.0 , 0.5 -0.9 Intermittent claudication , <0.5 Critical Ischemia , >1.1 ( calcified arteries in DM ) Duplex ultrasound MRI/CT angiogram digital subtraction and angiography
Management of PAD?
Conservative :smoking cessation, physical exercise ,dietary modification
medical : antiplatelet therapy ( aspirin ,clopidogrel ) , Statin , control blood pressure , tight glycemic control .
Cilostazol Which is phosphodiesterase inhibited which causes vasodilation
Pentoxifylline ; Xanthine derivative
Endovascular angioplasty stenting under local anesthesia
Surgical bypass procedure, synthetic craft craft vein graft examples at fem-pop bypass , fem -distal bypass , fem -fem cross over .
Amputation if none Viable limb.
Acute lower limb ischemia?
Causes?
Abrupt Interruption and perfusion that threatens viability of the lower limb.
Causes
acute thrombus with pre-existing arthrosclerosis a history of claudication
embolus : cardiac source from mural thrombus post MI , arrhythmias , IE ,prostheticHearth valves pre-existing arterial aneurysm
blue Toe syndrome which is etheroembolic debris resulting in a distal small arterial occlusion with a bluish discoloration of distal foot
other causes direct arterial trauma , arctic dissection popliteal aneurysm, Iatrogenic
Clinical features of acute lower limb ischemia?
6P :pain ,pallor, pulselessness ,perishing cold, paresthesia , paralysis
complication if untreated irreversible tissue damage within six hours limp loss and mortality
Types of amputation?
Digital Ray If gangrene extend to forefoot Transmetatarsal below knee Amputation through Knee amputation above knee amputation
Management of acute lower limb ischemia?
Give oxygen
don’t delay definite treatment
IV access and fluid if dehydrated
bloods FBC U&E coagulation profile ,troponin, glucose, group and safe
CXR , ECG , analgesia morphine
Give unfractionated heparin: starting those 5000 units then infusion of 1000 units ,Check APTT in four hours aim 60 to 90
Consider amputation if irreversible ischemia or swollen tender with the loss of power and sensation of limb
Consider embolectomy if obvious emboli with fasciotomy : Fogerty catheter to extract embolus
if limp is viable continue IV heparin plus CT Angio , thrombolysis plus angiography
Complications of reperfusion?
reperfusion injury
Rhabdomyolysis
Compartment Syndrome
