PAD - Peripheral Artery Disease

Question 1

Define PAD

Answer 1

Chronic insufficiency of arterial blood supply to the limbs due to vessel stenosis or occlusion

Question 2

What is the main cause of PAD?
Give 2 other rare causes?

Answer 2

Atherosclerosis

Fibromuscular Dysplasia
Vasculitis (takayasu, buerger’s)
Radiation-induced

Question 3

Give 10 RFs for PAD

Answer 3

Modifiable:
Smoking
HTN
Diabetes
Hypercholesterolaemia
Obesity/physical inactivity
Radiation-induced

Non-modifiable:
Male
Age >55
A.fib
Hypercoagulable state (anti-phospholipid)
Fam hx of atherosclerotic disease
Hyperhomocysteinemia
Vasculitis (Buerger’s, Takayasu)
Fibromuscular dysplasia

Question 4

What are the 2 main presentations via PAD? Define them

Answer 4

Intermittent claudication - Muscular pain in calves/buttocks exacerbated by exercise, relieved by rest

Critical limb ischaemia - Rest pain >2 weeks - pain in forefoot when lying flat, relieved by hanging leg over side of bed +/- ulcers gangrene necrosis

Question 5

What is Lyriche syndrome?
Give the triad

Answer 5

Occlusion at the bifurcation of the aorta at L4 causing triad of:
1) Buttock/thigh claudication
2) Absent/reduced femoral pulse
3) Erectile dysfunction

Question 6

What is the general presentation of PAD

Answer 6

6 Ps:
Pain:
Intermittent claudication - Muscular pain in calves/buttocks exacerbated by exercise, relieved by rest

Critical limb ischaemia - Rest pain >2 weeks - pain in forefoot when lying flat, relieved by hanging leg over side of bed +/- ulcers gangrene necrosis

Pallor
Perishingly cold
Pulselessness
Paraesthesia
Paralysis

Question 7

What is meant by Atrophic changes of PAD

Answer 7

Smooth Shiny skin
Hairless
Ulcers

Question 8

What is meant by tissue loss in PAD?

Answer 8

Ulcers, gangrene, necrosis

Question 9

What is the main tool used to grade PAD? Go through it

Answer 9

Fontaine Classification:
I - Asymptomatic
IIa - Intermittent claudication >200m
IIb - Intermittent claudication <200m
III - Rest pain (hanging leg)
IV - Tissue loss (ulcers, gangrene necrosis)

Question 10

How would you differentiate between a spinal pathology and PAD when taking a history

Answer 10

PAD: Relieved by stopping, worse when going uphill
Spine: Relieved by stopping + sitting down and better when going uphill

Question 11

What should be elicited in a hx of PAD?

Answer 11

SOCRATES for pain
When? differentiate between chronic, acute on chronic, or acute limb ischaemia
Intermittent claudication: How far? rest relieves? Pain at rest? At night? hanging leg?
!! If rest relieves do you they need to stop and sit or just stop for a bit and can continue?
Notice swelling?
Skin: Change of colour? Feet cold? Sores on legs that cannot heal? Painful!!?
Weakness of leg
Numbness
Previous Amputations

+ Previous history of ALI
+ Rule out DVT (warm to touch swelling)

RF for PAD: Smoking, cholesterol, !!diabetes, exercise, Family hx, Diagnosed with any genetic or autoimmune conditions

RF for Ischaemic limb: + A.fib, COCP/HRT, congenital thrombophilia, recent immobility, cancer

Question 12

What are your differentials for PAD?

Answer 12

Acute/chronic limb ischaemia/PAD/Leriche syndrome

Spinal stenosis
Osteoarthritis
Nerve entrapment (disc protrusion, bone metastasis, fracture)
DVT (venous claudication)
Trauma
Vasculitis (Buerger’s, Takayasu)

Question 13

How would you differentiate between an arterial and venous ulcer?

Answer 13

Question 14

How is a venous ulcer treated?

Answer 14

Conservative:
4-layered PROFORE dressing
Leg elevation
Venous support stockings

Medical:
Antibiotics if infection

Surgical:
Skin graft
Varicose vein surgery once ulcer healed to reduce recurrence rate

Question 15

What imaging is the best overall for detecting stenosis/occlusion of an artery casing PAD?

Answer 15

Duplex US

Question 16

What directly relevant investigations would you order for a patient with suspected PAD?

For imaging and procedure, combine them and list them in order of use and importance

Answer 16

Bedside: ABG + ECG (A.fib)
Bloods: Routine + thrombophilia screen
Procedures and imaging:
1) ABPI +!toe pressures
2) Duplex US to assess for stenosis/occlusion
3) CT/MR angiogram
4) DSA - Digital subtraction angiography

Question 17

which is preferred between CT and MR angiogram in PAD?

Answer 17

MR angiogram

Question 18

Discuss ABPI as you would in a long case

Answer 18

Mention toe pressures + image
Calcification in diabetes and CKD

Question 19

Take me through the conservative management of PAD

Answer 19

Question 20

Take me through the LL arterial supply

What muscle does the superficial femoral artery pass near to?
What arteries supply the different compartments of the leg?

Answer 20

Question 21

Symptom relief can be prescribed to patients with PAD. These drugs are not covered by the HSE and do not improve outcomes.
State the name of the 2 drugs and their MOA

Answer 21

Cilostazol: Phosphodiesterase inhibitor

Pentoxifylline: Xanthine derivative

both cause to vasodilation (cilostazol better)

Question 22

Give me a study to reference in PAD.

Answer 22

CLEVER study which compared outcomes in groups with supervised eercise training and other groups with stenting but not supervised exercise. The study concluded that those with supervised exercise had similar outcomes to those with stenting

Question 23

What medications are given to anything vascular?

why are these 2 meds given to anything vascular?

Answer 23

Antiplatelet therapy
+ Statin

These two enhance angiogenesis, vascular motor tone and have an anti-inflammatory effect together

The anti-platelet therapy is used more for preventing MI and stroke rather than PAD itself. IT DOES NOT DISSOLVE THE CLOT (thats what alteplase is for)

Question 24

What is the medical management of PAD

Answer 24

Question 25

List the surgical options for the treatment of PAD

Answer 25

Endovascular: Balloon Angioplasty +/- stenting
Surgical:
Endarterectomy
Bypass Procedure
Amputation

Question 26

Briefly describe angioplasty

Answer 26

1) General anaesthesia + Seldinger technique
2) Balloon covered with expandable metal stent passed
3) Balloon compresses plaque => widens lumen
4) Stent implanted

Question 27

Briefly explain what is an endarterectomy

Answer 27

Procedure to remove the atherosclerotic plaque
Involves surgically incising the artery and directly excising the plaque or intima layer

Closure via dacron or bovine patch

Question 28

What are the 2 types of grafts used in bypass procedures
List the benefits of each

Answer 28

Synthetic:
Better at handling pressure
+ Longer patency

GSV graft:
Reduced risk of infection
+ Better patency in smaller vessels
+ Honours: Can arterialise after being exposed to pressure

Question 29

What can synthetic grafts used in bypass procedures (PAD) most commonly made of (2)?

Answer 29

Dacron
PTFE

Question 30

List the most common types of bypasses and the graft type used for each

Answer 30

Axillo-Bifem (or just fem): Synthetic
Aorto-Bifem: Synthetic
Fem-Fem: Synthetic
Fem-Pop: Above knee = Synthetic, Below knee = GSV
Fem-Distal: GSV

Just another note: They can be separated also into anatomical and extra-anatomical (common sense)

Question 31

If they cannot harvest the GSV for a bypass, what other veins may be used?

Answer 31

SSV
Cephalic (UL)
Basilic (UL)

Question 32

What bypass would you use for a patient with Leriche Syndrome?

Answer 32

Obviously it depends where the occlusion is
Aorto-Bifem
Axillo-Bifem

Question 33

What is the full management of PAD? Do it ttek

Answer 33