Peripheral arterial disease Flashcards
What does peripheral arterial disease refer to
Narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas
What is intermittent claudication
Symptom of ischaemia in a limb, occurring during exertion and relieved by rest. It is typically a crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.
What is critical limb ischaemia
End-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest. The features are pain at rest, non-healing ulcers and gangrene. There is a significant risk of losing the limb.
What is acute limb ischaemia
Refers to a rapid onset of ischaemia in a limb.
Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.
Features of critical limb ischaemia
Pain Pallor Pulseless Paralysis Paraesthesia (abnormal sensation or “pins and needles”) Perishing cold
When is critical limb ischaemia pain usually worse
At night when the leg is raised, as gravity no longer helps pull blood into the foot
What is leriche syndrome
Leriche syndrome occurs with occlusion in the distal aorta or proximal common iliac artery.
Clinical triad in leriche syndrome
Thigh/buttock claudication
Absent femoral pulses
Male impotence
What can be used to accurately assess pulses when they are difficult to palpate
Hand-held doppler
Signs of arterial disease on inspection
Skin pallor Cyanosis Dependent rubor Hair loss Ulcers Poor wound healing Gangrene Muscle wasting
What is dependent rubor
A deep red colour when the limb is lower than the rest of the body
What is buerger’s test
Lift patient’s legs to 45 degrees while supine and hold for 1-2 mins looking for pallor
Pallor indicates arterial supply not adequate to overcome gravity suggesting PAD
Second part involves sitting patient up with legs hanging over side of the bed. In patient with PAD, legs will go blue initially and then dark red.
What does buerger’s angle refer to
Angle at which the leg is pale due to inadequate blood supply
Features of arterial ulcers
Are smaller than venous ulcers Are deeper than venous ulcers Have well defined borders Have a “punched-out” appearance Occur peripherally (e.g., on the toes) Have reduced bleeding Are painful lateral side of leg
Features of venous ulcers
Occur after a minor injury to the leg
Are larger than arterial ulcers
Are more superficial than arterial ulcers
Have irregular, gently sloping borders
Affect the gaiter area of the leg (from the mid-calf down to the ankle)
Are less painful than arterial ulcers
Occur with other signs of chronic venous insufficiency
Other features of chronic venous insufficiency
Haemosiderin staining
Venous eczema
IX for PAD
Ankle-brachial pressure index (ABPI)
Duplex ultrasound – ultrasound
Angiography (CT or MRI)
Normal ABPI
0.9-1.3
What does ABPI 0.6-0.9 indicate
Mild peripheral arterial disease
What does ABPI 0.3-0.6 indicate
Moderate to severe peripheral arterial disease
What does ABPI less than 0.3 indicate
Severe disease to critical ischaemic
What does ABPI above 1.3 indicate
Calcification of arteries making them difficult to compress(common in diabetics)
Lifestyle changes for management of intermittent claudication
Smoking cessation
Optimise medical treatment of co-morbidities(hypertension and diabetes)
Exercise training
Medical treatments for intermittent claudication
Atorvastatin 80mg Clopidogrel 75mg (aspirin if clopidogrel not suitable) Naftidrofuryl oxalate(peripheral vasodilator)
Surgical options for intermittent claudication
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
How can urgent revascularisation be achieved in critical limb ischaemia
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply
Management of acute limb ischaemia
Endovascular thrombolysis Endovascular thrombectomy Surgical thrombectomy Endarterectomy Bypass surgery Amputation of the limb if it is not possible to restore the blood supply
What is superficial thrombophlebitis
inflammation associated with thrombosis of one of the superficial veins, usually the long saphenous vein of the leg
Mx of superficial thrombophlebitis
NSAIDs
Compression stockings
What should all patients with peripheral arterial disease be commenced on
Atorvastatin 80mg
Clopidogrel
Acute mx of acute limb-threatening ischaemia
ABC approach
analgesia: IV opioids are often used
intravenous unfractionated heparin is usually given to prevent thrombus propagation, particularly if the patient is not suitable for immediate surgery
vascular review
