Peripheral arterial disease

Question 1

What does peripheral arterial disease refer to

Answer 1

Narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas

Question 2

What is intermittent claudication

Answer 2

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.

Question 3

What is critical limb ischaemia

Answer 3

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.

Question 4

What is acute limb ischaemia

Answer 4

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.

Question 5

Features of critical limb ischaemia

Answer 5

Pain
Pallor
Pulseless
Paralysis
Paraesthesia (abnormal sensation or “pins and needles”)
Perishing cold

Question 6

When is critical limb ischaemia pain usually worse

Answer 6

At night when the leg is raised, as gravity no longer helps pull blood into the foot

Question 7

What is leriche syndrome

Answer 7

Leriche syndrome occurs with occlusion in the distal aorta or proximal common iliac artery.

Question 8

Clinical triad in leriche syndrome

Answer 8

Thigh/buttock claudication
Absent femoral pulses
Male impotence

Question 9

What can be used to accurately assess pulses when they are difficult to palpate

Answer 9

Hand-held doppler

Question 10

Signs of arterial disease on inspection

Answer 10

Skin pallor
Cyanosis
Dependent rubor 
Hair loss
Ulcers
Poor wound healing
Gangrene 
Muscle wasting

Question 11

What is dependent rubor

Answer 11

A deep red colour when the limb is lower than the rest of the body

Question 12

What is buerger’s test

Answer 12

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.

Question 13

What does buerger’s angle refer to

Answer 13

Angle at which the leg is pale due to inadequate blood supply

Question 14

Features of arterial ulcers

Answer 14

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

Question 15

Features of venous ulcers

Answer 15

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

Question 16

Other features of chronic venous insufficiency

Answer 16

Haemosiderin staining

Venous eczema

Question 17

IX for PAD

Answer 17

Ankle-brachial pressure index (ABPI)
Duplex ultrasound – ultrasound
Angiography (CT or MRI)

Question 18

Normal ABPI

Answer 18

0.9-1.3

Question 19

What does ABPI 0.6-0.9 indicate

Answer 19

Mild peripheral arterial disease

Question 20

What does ABPI 0.3-0.6 indicate

Answer 20

Moderate to severe peripheral arterial disease

Question 21

What does ABPI less than 0.3 indicate

Answer 21

Severe disease to critical ischaemic

Question 22

What does ABPI above 1.3 indicate

Answer 22

Calcification of arteries making them difficult to compress(common in diabetics)

Question 23

Lifestyle changes for management of intermittent claudication

Answer 23

Smoking cessation
Optimise medical treatment of co-morbidities(hypertension and diabetes)

Exercise training

Question 24

Medical treatments for intermittent claudication

Answer 24

Atorvastatin 80mg 
Clopidogrel 75mg (aspirin if clopidogrel not suitable) 
Naftidrofuryl oxalate(peripheral vasodilator)

Question 25

Surgical options for intermittent claudication

Answer 25

Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery

Question 26

How can urgent revascularisation be achieved in critical limb ischaemia

Answer 26

Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply

Question 27

Management of acute limb ischaemia

Answer 27

Endovascular thrombolysis
Endovascular thrombectomy
Surgical thrombectomy 
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply

Question 28

What is superficial thrombophlebitis

Answer 28

inflammation associated with thrombosis of one of the superficial veins, usually the long saphenous vein of the leg

Question 29

Mx of superficial thrombophlebitis

Answer 29

NSAIDs

Compression stockings

Question 30

What should all patients with peripheral arterial disease be commenced on

Answer 30

Atorvastatin 80mg

Clopidogrel

Question 31

Acute mx of acute limb-threatening ischaemia

Answer 31

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