Peripheral Arterial Disease

Question 1

intermittent claudication

Answer 1

peripheral arterial disease affects the arteries supplying the legs, mostly caused by atherosclerosis

Restriction of blood flow, due to arterial stenosis or occlusion, often leads patients to complain of a cramping muscle pain on walking (intermittent claudication). Any further reduction in blood flow causes ischaemic pain at rest, which affects the foot. Ulceration and gangrene may then supervene and can result in loss of the limb if not treated

Question 2

what score is used to classify the severity of ischaemia

Answer 2

fontaine

Question 3

stage I fontaine

Answer 3

asymptotic

Question 4

stage II fontaine

Answer 4

intermittent claudication

Question 5

stage III fontaine

Answer 5

ischaemic pain at rest

Question 6

stage IV fontaine

Answer 6

gangrene and or ulceration

Question 7

intermittent claudication clinical features

Answer 7

• A history of muscular, cramp-like pain on walking that is rapidly relived by resting, together with absent pulses
• cold, white hairless legs
• atrophic skin
• arterial ulcers (relieved by hanging leg out bed, punched out appearance)

Question 8

which pulses are absent in intermittent claudication?

Answer 8

follows anatomy, revise this

Question 9

what does a prominent popliteal pulse suggest

Answer 9

possibility of a popliteal aneursym

Question 10

examination of intermittent claudication

Answer 10

• ABPI
• Toe CRT >15seconds
• Buerger’s angle <20 degrees

Question 11

which ABPI value suggests claudication

Answer 11

<0.9

Question 12

what does ABPI normally do during exercise, and what does it do in intermittent claudication

Answer 12

normally increases

decreases in intermittent claudication

Question 13

Buerger’s angle

Answer 13

• Buerger’s test is used to test arterial insufficiency
• The Buerger’s angle is the degree to which the leg can be raise before it goes pale
• Normal legs can go past 90 degrees

Question 14

investigation of intermittent claudication

Answer 14

• duplex ultrasound scanning is first line
• magnetic resonance angiography
• CT angiography
• catheter angiography

Question 15

what are the pros of duplex US scanning

Answer 15

• non invasive
• can delineate the anatomical site of the disease

Question 16

treatment of intermittent claudication

Answer 16

risk factor modification:

• STOP SMOKING - essential
• Exercise – walking develops collateral circulation
• Treat hypertension and high cholesterol
• Prescribe an anti-platelet to prevent progression and reduce CV risk – clopidogrel is recommended

Question 17

what pharamcological treatment is available to treat intermittent claudication

Answer 17

Cilostazol

Question 18

use of angioplasty and stenting in intermittent claudication

Answer 18

• balloon angioplasty is useful when disease is limited to a single segment
• stenting is used to maintain arterial patency

Question 19

available surgery for intermittent claudication

Answer 19

• endarectomy: surgical removal of part of the inner lining of an artery with the atheromatous plaque
• arterial reconstruction with bypass graft: consider this if atheromatous disease is extensive but distal run-off is good (e.g. distal arteries filled with collateral vessels)
• amputation

Question 20

acute limb ischaemia

Answer 20

Sudden lack of blood flow to a limb, e.g. caused by an embolus. This is a surgical emergency requiring revascularization within 4-6 hours

Question 21

critical limb ischaemia

Answer 21

an advanced stage of peripheral arterial disease, defined as a triad of ischaemic rest pain, gangrene and arterial insufficiency ulcers

Question 22

what is the prognosis of Critical Limb Ischaemia

Answer 22

negative, high amputation rates

Question 23

typical history of a patient with Critical Limb Ischaemia

Answer 23

• deteriorating claudication, progressing to nocturnal rest pain
• ischaemia and gangrene from minor trauma
• hanging foot out bed increases perfusion