Peripheral arterial disease

Question 1

palpable pulses

Answer 1

aorta, common femoral, political, postural tibial, dorsals pedis

Question 2

chronic ischaemia

Answer 2

atherosclerotic disease of arteries supplying lower limb, same disease process as coronary and carotid atherosclerotic disease

Question 3

risk factors of CLI

Answer 3

male, age, smoking, hypercholesterolaemia, hypertension, diabetes

Question 4

fontaine classification

Answer 4

used to classify the severity of CLI.
stage 1 asymptomatic, incomplete blood vessel obstruction
stage 2 mild claudication pain in limb 2A when walking a distance greater than 200 meters, 2B when walking less than 200 meters
stage 3 rest pain, mostly in feet
stage 4 necrosis and or gangrene of limb- critical

Question 5

history of CLI

Answer 5

exercise tolerance, effect of incline, change over time, relieves by rest? where in leg? type of pain? bilateral? rest pain type of pain and relieving factors? tissue loss when how long what feels like? risk factors, past MH, drug history, occupational, surgical history

Question 6

clinical examination of CLI

Answer 6

look at both legs- ulceration, pallor, hair loss, temperature, capillary refill time, peripheral sensation, pulses, auscultate hand held doppler- dorsals pedis and posterior tibial pulses

Question 7

special examination tests

Answer 7

ankle brachial pressure index, buergers test

Question 8

ankle brachial pressure index

Answer 8

normal- 1 or more, intermittent claudication- 0.95-0.5, rest pain- 0.5-0.3, gangrene and ulceration less than 0.2

Question 9

buergers test

Answer 9

elevate legs - pallor, hang feet over edge of bed, slow to regain colour then go dark red colour

Question 10

investigations for CLI

Answer 10

duplex, CTA/MRA, digital subtraction angiography

Question 11

duplex scan

Answer 11

dynamic, no radiation or contrast, not good in abdomen, operator dependent

Question 12

CTA/MRA

Answer 12

detailed, allows treatment planning, first line according to NICE, contrast and radiation, can overtime calcification

Question 13

medical therapy for CLI

Answer 13

combination of antiplatelet and statin

Question 14

antiplatelets do what

Answer 14

reduce risk of requiring revascularization as well as cardiovascular and all cause mortality

Question 15

statins do what

Answer 15

inhibit platelet activation and thrombosis, endothelial and inflammation activation, plaque rupture

Question 16

risk factors control

Answer 16

BP controlled to less than 140/85, smoking cessation, diabetic control

Question 17

revascularisation modalities

Answer 17

open surgery eg bypass and or endarterectomy, endovascular intervention eg balloon angioplasty, stent placement, atherectomy

Question 18

surgical bypass require

Answer 18

good inflow, a conduit ie autologous or synthetic , good outflow

Question 19

reintervention rate of surgical bypass is

Answer 19

18.3-38.9%

Question 20

two main types of bypass

Answer 20

aortobifemoral bypass of common femoral to below the knee popliteal bypass

distal bypass common femoral to posterior tibial artery

Question 21

what is better surgical vascular repair or end-vascular repair

Answer 21

surgical if pros outweigh the cons and if life expectantly reasonable and if limb anatomy is correct

Question 22

acute limb ischaemia causes

Answer 22

arterial embolus, or thrombosis, trauma, dissection, acute aneurysm thrombosis

Question 23

clinical presentation ALI

Answer 23

6Ps- pain pallor pulse deficit parasthesia paresis or paralysis and polikilothemia. compare with contralateral limb

Question 24

compartment syndrome

Answer 24

muscle ischeamia, inflammation, oedema, venous obstruction, tense and tender calf, rise in creatinine kinase, risk renal failure due to myoglobulinaemia

Question 25

clinical categories of acute limb ischaemia

Answer 25

viable, threatened- marginally or immediately, irreversible

Question 26

irreversible acute limb ischaemia

Answer 26

major tissue loss or permanent nerve damage, profound sensory loss, paralysis or profound muscle weakness, inaudible arterial andvenous doppler sounds

Question 27

immediately acute limb ischaemia

Answer 27

salvageable with immediate revascularisation, more than toes sensory loss, associated with rest pain, mild or moderate muscle weakness and no artery doppler signals but there are venous

Question 28

how much of ALI is embolic and thrombotic

Answer 28

30%, 60%

Question 29

when does irreversible muscle ischaemia occur

Answer 29

in 6-8 hours

Question 30

peri operative mortality rate

Answer 30

22%

Question 31

how many diabetics will develop a foot ulser and how many of those become infected or need amputation

Answer 31

25%, 50%, 20%

Question 32

pathophysiology of diabetic foot ulcer

Answer 32

microvascular peripheral artery disease, peripheral neuropathy, mechanical imbalance, foot deformity, minor trauma, susceptibility to infection

Question 33

treatment of DFU

Answer 33

prevention- always wear shoes, check fit of footwear, check pressure points/plantar surface regularly, prompt and regular wound care of skin breaches, effective glycemic control. suspect infection start patient on antibiotics, investigate for osteomyelitis, gas gangrene and necrotising fasciitis. revascularisation, amputation