Peripheral arterial disease Flashcards
What causes peripheral arterial disease (PAD)?
It occurs due to atherosclerosis causing stenosis of arteries via a multifactorial process involving modifiable and non-modifiable risk factors
What is done to initially investigate someone with suspected PAD ?
- History
- Exammination of peripheral pulses - femoral, popliteal and foot pulses (dorsalis pedis and post. tibial)
- Abdominal palpation for aneurysm
Following initial history and exammination of someone with suspected PAD what is the 1st line investigation you should do ?
Ankle brachial pressure index (ABPI)
Using ABPI how is PAD classified ?
- Normal = >0.9 - 1.2
- PAD/intermittend claudication = 0.5-0.9
- Critical limb ischaemia = <0.5
When should care be taken when interpreting the ABPI values and why?
- In patinets with DM and advanced CKD - there vessels may be incompressable causing abnormally high results
- In these patients with high results of 1.5 and above think of this as the possible cause
Can you exclude a diagnosis of PAD based on ABPI alone in someone with diabetes ?
No - Do not exclude a diagnosis of PAD in people with diabetes based on a normal or raised ABPI alone.
What are the signs/symptoms of intermittend claudication ?
- Intermittent claudication: aching or burning in the leg muscles following walking
- Patients can typically walk for a predictable distance before the symptoms start
- Usually relieved within minutes of stopping
- Pain not present at rest
What are the features suggestive of critical limb ischaemia ?
Features should include 1 or more of:
- rest pain in foot for more than 2 weeks
- ulceration
- gangrene
- Patients also often report hanging their legs out of bed at night to ease the pain.
- Pain is worse at night and helped by getting up and walking about
- Cool to touch
- Absence of peripheral pulses
- Colour change
- Poor tissue nutrition - hairless, thick nails, shiny skin
- Venous guttering
- Ulcers
- Gangrene
Following history, exammination and ABPI, what is the next investigation which should be done in someone with suspected PAD?
1st line = Duplex ultrasound - for whom revascularisation is being considered
If further imaging is required for patients with PAD being considered for revascularisation what should be done ?
- 1st line = contrast‑enhanced magnetic resonance angiography (MRA)
- 2nd line = CT angiography if MRA is contraindicated or not tolerated. (as MRA uses contrast)
What conditions are people with PAD often co-morbid for and therefore require treatment for alongside the treatment specifically for their PAD?
- hypertension
- diabetes mellitus
- obesity
Follow standard treatment for these things
What is the standard specific treatment of intermittent claudication?
- Supervised exercise programme - 2 hours of supervised exercise a week for a 3‑month period, beyond pain
- Statin - Atorvastatin 80 mg + Clopidogrel (aspirin 2nd line)
- Modify risk factors e.g. stopping smoking
After the standard treatment of intermittent claudication what is the next step in treatment and when is it considered?
1st line = angioplasty + stenting
Considered when a supervised exercise programme has not led to a satisfactory improvement in symptoms and imaging has confirmed that angioplasty is suitable for the person
If angiography + stenting is not suitable for someone with intermittent claudication what is the next treatment option and when is it offered ?
Bypass surgery and graft
Offer bypass surgery for treating people with severe lifestyle‑limiting intermittent claudication only when:
- angioplasty has been unsuccessful or is unsuitable and
- imaging has confirmed that bypass surgery is appropriate for the person.
When should Naftidrofuryl oxalate be used in the treatment of intermittent claudication ?
Only when:
- supervised exercise has not led to satisfactory improvement and
- the person prefers not to be referred for consideration of angioplasty or bypass surgery.
