PAD (claudication and critical ischaemia)

Question 1

PAD (claudication and critical (limb) ischaemia): Definition

Answer 1

• PAD is an abnormal narrowing of arteries other than those that supply the heart or brain
  
  • When narrowing occurs in the heart, it is called coronary artery disease
  • and in the brain, it is called cerebrovascular disease.
• ie. ‘PAD includes a range of arterial syndromes that are caused by atherosclerotic obstruction of the lower-extremity arteries.’
• Claudication
  
  • ​a medical term usually referring to impairment in walking, or pain, discomfort, numbness, or tiredness in the legs that occurs during walking or standing and is relieved by rest
• Critical (limb) ischaemia
  
  • ​an advanced stage of peripheral artery disease (PAD).
  • It is defined as ischemic rest pain with tissue loss (arterial insufficiency ulcers & gangrene (tissue death due to lack of blood supply))
    
    • tissue loss reflects the development of surface damage to the limb tissue due to the most severe stage of ischemia

Question 2

PAD (claudication and critical (limb) ischaemia): Aetiology

Answer 2

• maj atherosclerosis

also

• arterial spasm
• thrombosis
• fibromuscular dysplasia

Question 3

PAD (claudication and critical (limb) ischaemia): Risk factors

Answer 3

Same as atherosclerosis

• Smoking
• Hyperglycaemia
• Dyslipidemia
• HTN
• etc

Question 4

PAD (claudication and critical (limb) ischaemia): Pathophysiology

Answer 4

• Pretty much just atherosclerosis

Question 5

PAD (claudication and critical (limb) ischaemia): Cinical manifestations: key presentations, other symptoms and signs

Answer 5

• Most patients are asymptomatic
• May experience walking issues with claudication
  
  • ​‘Severe cramp’ on exercise which resolves when they stop walking.
  • Often worse going uphill but never at rest. This is called intermittent claudication.
  • Claudication refers to pain in the thigh, calf or buttocks when walking
• May experience gangrene/ ulceration with critical limb ischaemia
• most patients will have atleast 1 risk factor
  
  • smoking
  • diabetes
  • hypertension
  • elevated C-reactive protein (CRP)

Signs:

• Lower limbs are cold with dry skin and lack of hair
• Pulses may be diminished or absent
• ‘6 Ps’: pulseless, pain, pallor, paraesthesia, paralysis, perishingly cold

Question 6

PAD (claudication and critical ischaemia): Investigations (diagnosis): 1st line, gold standard & other

Answer 6

• Ancle-Brachial Index (see pic)
  
  • the ratio of the blood pressureat the ankle to the blood pressure in the upper arm (brachium).
  • Compared to the arm, lower blood pressure in the leg suggests blocked arteries due to peripheral artery disease (PAD)
• Doppler ultrasound

Question 7

PAD (claudication and critical ischaemia): DDx

Answer 7

• Spinal stenosis
• Arthritis
• Venous claudication

Question 8

PAD (claudication and critical ischaemia): Management

Answer 8

• Lifestyle
  
  • NO SMOKING
  • more excersize
• Medication
  
  • treat HTN
  • treat diabetes
  • treat high cholesterol
  • antiplatelets
    
    • asprin
    • clopidogrel
• Revascularisation
  
  • Angioplasty
  • Atherectomy
  • (plaque is scraped off of the inside of the vessel wall)
  • ascular bypass
• If gangrene
  
  • amputation to prevent sepsis of infected necrotic tissue