Peripheral Arterial Disease Flashcards
Chief feature of PAD
Intermittent Claudication
65% have coexisting disease of what?
Cerebral or coronary artery disease
2 types of PAD?
Acute Limb Ischaemia
Chronic Limb ischaemia
Difference betweeen Acute Limb Ischaemia and chronic limb ischaemia in terms of pathophysiology?
Acute = Usually due to an embolus (emboli broken off causing sudden onset blockage in a smaller artery)
Chronic = Usually due to a thrombus (static blockage that gets bigger till it causes an occlusion over time)
Acute/Chronic limb ischaemia
Which one is a surgical emergency?
What needs to be done?
Within how long?
Acute Limb Ischaemia
Surgical revascularisation
4-6 hours
RF for chronic limb ischaemia
HTN Smoking T2DM High cholesterol Obesity
RF for acute limb ischaemia
AF
Aneurysm (dilated blood vessel - turbulent flow - clots form leading to emboli).
Chronic Limb ischaemia - how does it overcome obstruction?
Developing collaterals over time
Two types of chronic limb ischaemia
Critical and non-critical
Critical - rest pain and having to sleep in chair + collaterals can’t cope.
Tx of Acute Limb ischaemia
urgent open surgery or angioplasty
within 6 hours:
- embolectomy (if done after 6hrs - risk of compartment syndrome)
longer than 9 hours:
- fasiotomy (fascia - relieve pressure)
OR
local thrombolysis (tissue plasminogen activator t-Pa)
Tx of Chronic Limb Ischaemia
what are the conservative and medical measures?
if these have failed?
conservative:
encourage exercise (3x30mins) to improve collateral flow - exercise till point of maximal pain, quit smoking, treat HTN and cholesterol
medical:
- statin + antiplatelet (clopidogrel - 1st line) - reduce risk of critical ischaemia
- naftidrofuryl oxalate - for those not intending to undergo revascularisation + if exercise fails to improve symptoms
surgical:
* angioplasty (can’t angioplasty an occlusion (block) but you can for stenosis (narrowing)). used only if affecting one arterial segment of a single artery - stent used via ballon inflation
- surgical reconstructon - if extensive but run-off is good (collaterals fill distal vessels) - do bypass graft
- amputation - patient’s decision - if ongoing pain - preserve knee
Six P’s for Acute Limb Ischaemia
Painless Pulseless Perishingly cold Parasthesia Paralysis Pallor
Features of Critical Ischaemia
Rest pain
Burning pain at night relieved by hanging legs over side of bed or sleeping in chair
Ulceration
Gangrene
Calf claudication a sign of?
femoral disease
Buttock claudication a sign of?
iliac disease
Classification for PAD?
Fontaine’s classification
- Asymptomatic
- Intermittent claudication
- Foot pain at rest
- Ulceration/gangrene (critical ischaemia)
What is a +ve Buerger’s angle when raising leg off couch
<20 degrees - see leg go pale
signs of PAD
Absent distal pulses
cold, white legs
postural dependent colour change
ulcers
Ix for PAD
1) do a thrombophilia screen in which patients?
2) CRP/ESR to exclude what?
3) ABPI?
1) <50yrs
2) DM or arteritis
3) Ankle Brachial Pressure Index
- Normal (1-1.2
- PAD (0.4-0.9)
- Critical Limb ischaemia (<0.4)
- DM (>1.2) - incompressible calcified vessels from atherosclerosis
1st line imaging for PAD?
Colour Duplex US
if considering intervention for PAD:
what imaging would you then choose?
MRI/CT Angiography
if in doubt with diagnosis of acute limb ischaemia what would you do before surgical intervention
urgent arteriography
in acute limb ischaemia management - what do you do once you’ve done either a embolectomy or fasciotomy
anticoagulate with heparin
What can be used to treat the complication of phantom limb pain in amputation
Gabapentin
A 69-year-old man attends his GP with symptoms of intermittent claudication. He has a past medical history of gastro-oesophageal reflux for which he takes lansoprazole. On examination he has absent dorsalis pedis pulses in both feet, his blood pressure is 134/85 mmHg and his heart rate is 82 bpm. An ankle-brachial pressure index is performed which confirms a diagnosis of peripheral arterial disease.
Which of the antiplatelet agents are most appropriate as first line treatment for this gentleman?
Clopidogrel
A 62-year-old man with intermittent claudication is reviewed. He is currently taking clopidogrel and simvastatin. Despite regular exercise he is still symptomatic. Clinical examination shows no signs of critical limb ischaemia. Which one of the following interventions should be considered next?
Angioplasty Amlodipine Amputation Isosorbide Mononitrate Compression stockings
Angioplasty
A 65-year-old man presents to his GP with bilateral ‘burning sensation’ at the back of his legs after walking approximately 100 yards. This sensation is relieved by rest.
His ankle brachial pressure index (ABPI) is 0.8.
What is the first-line imaging to investigate this patient further?
Duplex US
A 66-year-old man reports that he is struggling to walk his dog as he finds that his calves are intensely painful after about 10 mins. A lower limb examination is normal aside from absent posterior tibial and dorsalis pedis pulses. His past medical history includes a myocardial infarction 3 years ago and he also smokes 30/day.
Given the likely diagnosis, which medication should he be prescribed daily for secondary prevention of cardiovascular disease?
Clopidogrel 75mg
A 28-year-old man undergoes a ileocaecal resection and end ileostomy for Crohn’s disease. One year later he presents with a deep painful ulcer at his stoma site
Pyoderma gangrenosum is associated with inflammatory bowel disease. It is commonly found on lower limbs and described as being painful, the size of an insect bite and growing.
A 24-year-old lady from Western India presents with symptoms of lethargy and dizziness, worse on turning her head. On examination her systolic blood pressure is 176/128. Her pulses are impalpable at all peripheral sites. Auscultation of her chest reveals a systolic heart murmur
Takayasu’s arteritis most commonly affects young Asian females. Pulseless peripheries are a classical finding
A 55-year old-man comes to see you saying that his father recently died of an abdominal aortic aneurysm.
He asks whether he will be screened for this condition and at what age?
Single Abdo US at age 65
A 73-year-old lifelong heavy smoker presents to the vascular clinic with symptoms of foot ulceration and rest pain. On examination her foot has areas of gangrene and pulses are impalpable.
What is their ABPI?
0.3
A 63-year-old man presents with a claudication distance of 15 yards. He is a lifelong heavy smoker. On examination his foot is hyperaemic and there is a small ulcer at the tip of his great toe.
What is their ABPI?
0.5
A 77-year-old morbidly obese man with type 2 diabetes presents with leg pain at rest. His symptoms are worst at night and sometimes improve during the day. He has no areas of ulceration
What is their ABPI?
> 1.2
