Peripheral arterial disease

Question 1

Peripheral arterial disease definition

Answer 1

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

Question 2

Intermittent claudication definition

Answer 2

Symptom of ischaemia in limbs
Occurs in exertion, relieved by rest
Crampy, achy pain in calf, thigh or buttocks
Muscle fatigue when walking beyond a certain intensity

Question 3

Critical limb ischaemia

Answer 3

End-stage PAD
Inadequate supply of blood to a limb to allow it to function normally at rest
5 P’s:
Pain at rest - burning, worse at night when leg is raised
Pallor
Paralysis
Paraesthesia
Perishing cold

Non-healing ulcers
Gangrene
Risk of losing limb

Question 4

Acute limb ischaemia

Answer 4

Rapid onset of ischaemia in a limb
Thrombus blocks arterial supply

Question 5

Necrosis definition

Answer 5

Death of tissue

Question 6

Ischaemia definition

Answer 6

Inadequate oxygen supply due to reduced blood supply

Question 7

Gangrene definition

Answer 7

Death of tissue due to inadequate blood supply

Question 8

Leriche syndrome

Answer 8

Occlusion in distal aorta or proximal iliac artery
Triad:
Thigh/buttock claudication
Absent femoral pulses
Male impotence

Question 9

PAD signs

Answer 9

Peripheral pulses weak on palpitation/with doppler
Skin pallor
Cyanosis
Dependent rubor (red colour when limb is lower than body)
M wasting
Hair loss
Ulcers
Poor wound healing
Gangrene (breakdown of skin and red/black colouration)
Reduced skin temperature
Reduced sensation
Prolonged CRT
Buerger’s test

Question 10

Buerger’s test

Answer 10

Pt lies supine
Lift legs to 45 degrees for 1-2 minutes
If pallor - arteries cannot overcome gravity - PAD
Buerger’s angle - angle at which leg goes pale

Sit pt up with legs hanging over side of bed
Gravity should help blood flow back
Blue - as ischaemic tissue deoxygenates blood
Dark red - vasodilation in response to waste products of anaerobic respiration (rubor)

Question 11

Arterial ulcers

Answer 11

Ischaemia secondary to inadequate blood supply
Smaller
Deeper
Well defined borders
Punched out appearance
Occur peripherally
Reduced bleeding
Painful

Question 12

Venous ulcers

Answer 12

Impaired drainage and pooling of blood in legs
After minor injury
Larger
Superficial
Irregular, gently sloping borders
Affect gaiter area (mid calf to ankle)
Less painful
Other signs of chronic venous insufficiency (haemosiderin staining and venous eczema)

Question 13

PAD investigations

Answer 13

Ankle-brachial pressure index (ABPI)
Duplex USS - speed and volume of blood flow
Angiography (CT or MRI) with contrast

Question 14

ABPI

Answer 14

Ratio of systolic BP in ankle compared to (divided by) systolic BP in arm
Doppler
0.9-1.3 = normal
0.6-0.6 = mild PAD
0.3-0.6 = severe PAD
<0.3 = severe to critical ischaemic
>1.3 = calcification (diabetic)

Question 15

Management of intermittent claudication

Answer 15

Lifestyle changes
Exercise training
Atorvastatin 80mg
Clopidogrel 75mg OD
Naftidrofuryl oxalate - peripheral vasodilator - 5-HT2 receptor antagonist
Endovascular angioplasty and stenting
Endarterectomy - cut vessel open and remove plaque
Bypass surgery

Question 16

Management of critical limb ischaemia

Answer 16

Urgent referral to vascular
Endovascular angioplasty and stending
Endarterectomy
Bypass surgery
Amputation

Question 17

Management of acute limb ischaemia

Answer 17

Urgent referral to vascular
Endovascular thrombolysis - thrombolysis directly into clot
Endovascular thrombectomy
Surgical thrombectomy
Endartectomy
Bypass surgery
Amputation