Peripheral arterial disease Flashcards by Ross Lilley

what is are the causes of chronic limg ischaemia?

atherosclerosi or the arteries supplying the lower limb
less commonly:
vasculitis and Buerger’s disease (Thromboangiitis obliterans)

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what is Buerger’s disease?

rare disease of the arteries and veins in the arms and legs. In Buerger’s disease, your blood vessels become inflamed, swell and can become blocked with blood clots

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what are the risk factors for chronic limb ischaemia?

male 
age
smoking
hypercholesterolaemia
hypertension
diabetes

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what is the Fontaine class I chronic limg ischaemia?

Asymptomatic, incomplete blood vessel obstruction

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what is the Fontaine class IIA chronic limg ischaemia?

Mild claudication pain in limb claudication when walking a distance of greater than 200 meters

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what is the Fontaine class IIB chronic limg ischaemia?

mild claudication pain in limb claudication when walking a distance of less than 200 meters

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what is the Fontaine class III chronic limg ischaemia?

Rest pain, mostly in the feet

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what is the Fontaine class IV chronic limg ischaemia?

Necrosis and/or gangrene of the limb

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what must be picked up in the history for chronic limb ischaemia?

claudication: exercise tolerance, effect of incline, change over time, relief from rest, where in leg, type of pain
rest pain: type and relieving factors
tissue loss: duration, history of trauma, peripheral sensation
risk factors
PMH- hypertension, DM, hypercholesterioaemia
DH- prothrombotic and antithrombotic factors
SH-smoking
OH- effect of claudication on job

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what are the signs of chronic limb ischaemia?

ulceration
pallor
hair loss
palpate- 
capillary refil reduced
temperature reduced
pulses reduced or absent
peripheral sensation reduced
auscultate with hand held doppler over dordalis pedis and posterior tibial pulses.

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doppler auscultation over the dorsalis pedis will show what in healthy, more unhealthy and very unhealthy arteries?

healthy- triphasic nature
unhealthy- biphasib
very unhelathy- monophasic

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what are the specialist tests caried out for chronic limg ischaemia?

Ankle Brachial Pressure Index

Buerger’s test

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how do you calculate ankle brachial pressure index?

ankle pressure divides by brachial pressure. the lower it is the more severe the chronic limb ischaemia

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what does a ABPI of 1 or more indicate?

symptom free I

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what does a ABPI of 0.95-0.5 indicate?

CLI causing intermettent claudication

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what does a ABPI of 0.5-0.3 indicate?

CLI causing pain at rest

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what does a ABPI of <0.2 indicate?

gangrene and ulceration

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describe BUerger’s test for CLI?

elevate legs if there is pallor with < 20 degrees elevation then there is severe ischaemia
fee are then hung over the edge of the bed. In CLI the feet are slow to regain colour and turn a dark red colour.

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what is the best medical therapy for CLI?

antiplatelet
statin
BP control 
smoking cessation
exercise
biabetic control

what is the purpose of statins in the treatment of CLI?

stabilise plaque to prevent embolisation and thrombus formation

what is the BP target for CLI?

<140/85

why does exercise increase the symptoms of CLI?

increases collateral circulation and trains muscle to work in ischaemic conditions.

what is the treatment of moderate CLI?

best medical therapy only

what is the tretament of severe CLI?

BMT
anioplsty/stenting
surgical bypass

what is the treatment of critical CLI?

BMT angioplasty/stent endovascular reconstruction surgical bypass/stent

what are the imaging investigations carried out for CLI?

duplex CTA magnetic resonance angiography

what are the pros and cons of duples on CLI?

pros Dynamic No radiation/contrast cons Not good in the abdomen Operator dependent, time consuming

what are the pros and cons of CTA and MRA in CLI?

pros Detailed – allows treatment planning First line according to NICE cons Contrast and radiation Can overestimate calcification, difficulty in low flow states

what is needed for a surgical bypass graft for CLI?

Inflow A conduit: autologous (vein from legs, arm), synthetic (PTFE/Dacron) Outflow

what are the risk and complications of surgical bypass for CLI?

``` bleeding wound infection pain scar DVT and PE (despite systemic heparin) MI CVA LRTI death damage to nearby: vein, artery, nerve distant emboli graft failure (stenosis, occlusion) ```

what are the sites of amputation if lower limb/foot cannot be saved by angioplasty/stenting or bypass?

``` above knee below knee transmetarsal digit hip disarticulation hindquarter through knee symes (ankle) ```

what is the aetiology of acute limb ischaemia?

arterial embolus from: MI, AF, proximal atherosclerosis (not DVT and PE) thrombosis from previously diseased artery trauma dissection acute aneurysm thrombosis

what must be found in the history of acute limb ischaemia?

``` history of chronic limb ischaemia risk factors cardiac histry onset/duration of symptoms functional status ```

what is teh presentation (signs) of acute limb ischaemia

``` pain pallor perishingly cold paraesthesia paralysis pulseless ``` compare with contralateral limb and is it reversible

what is compartment syndrome?

build up of pressure in muscle compartments

describe the pathophysiology of compartment syndrome?

1. the build up of pressure in the compartment causes obstruction of venous flow 2. this leads to oedema 3. this leads to reduced arterial flow and muscle ischaemia 4. ultimately this leads to renal failure (myogloulinaemia)

what are the signs of compartment syndrome?

tense, tender calf, rise in creatinine kinase

what is the management of compartment syndrome?

fasciotomy`

what is the management of ALI?

``` ECG bloods analgesia anticoagulate nil by mouth in case of surgery ```

what is the management of ALI caused by embolus?

embolectomy

what is the management of ALI caused by thrombosis in situ?

endovascular mechanical thrombectomy thrombolysis open embolectomy +/- bypass

what is the management of acute limb ischaemia if the limb is not slavagable?

palliation | amputation

what is the pathophysiology of diabetic foot disease?

Microvascular peripheral artery disease Peripheral neuropathy Mechanical imbalance Susceptibility to infection

how can diabetic foot disease be prevented?

``` footcare glycaemic control (wear shoes, check fit of shoes, check presssure points regularly, prompt and regular woundcare) ```

what is the management of diabetic foor disease?

- prevention - good wound care - tracking infection- consider systemic antibiotics - investigate for osteomyelitis, gas gangrene, necrotising fasciitis - revascularisation ( distal crural angioplasty /stent, distal bypass - amputation

what are the reascularising techniwues for diabetic fot disease?

attempt distal crurual angioplasty/stent (if disease very distal) distal bypass