Peripheral Arterial Disease: Intermittent Claudication ☺️

Question 1

Presentation of intermittent claudication

Answer 1

Intermittent claudication

• predictable distance => somatic leg pain on exertion
• relieved with rest

Question 2

Symptom and the anatomical site of obstruction

Answer 2

Bottom, hip - aorto iliac
Thigh - aorto iliac/common iliac
Upper 2/3 of calf - superficial femoral
Lower 1/3 of calf - popliteal
Foot claudication - tibial/peroneal

Question 3

Investigations

Answer 3

Pulse check
-femoral, popliteal, post tibialis, dorsalis pedis
1st line - duplex US => confirm absent pulses
-combines doppler, US

ABPI check

• Bilateral brachial, ankle (between post tibial and dorsalis pedis) BP measured while supine
• higher R ankle pressure/higher arm pressure
• higher L ankle pressure/higher arm pressure

Question 4

Management of intermittent claudication

• lifestyle
• medication
• interventions

Answer 4

Smoking cessation
Exercise training to pain => build collaterals
Comorbidity management
-2ndary risk management - clopidogrel 75mg
-lipid => atorvastatin 80mg
-HTN, DM
-obesity

Severe PAD

• VD - naftidrofuryl oxalate
• angioplasty, stenting, bypass

CLI + unsuitable for interventions => amputation

Question 5

Presentation of critical limb ischemia and acute limb ischemia
-how to differentiate between the 2

Answer 5

Critical limb ischemia - ischemic rest pain over 2wks+

• pink, pale
• weak/no pulse
• ulcers, gangrene

Acute limb-threatening ischemia - 6Ps developing U2wks

• sudden rest pain
• marble white skin

Question 6

How to differentiate between embolic vs thrombotic ALL

-why is this important

Answer 6

Emboli - sudden, no time to build collaterals

Thrombotic

• gradual onset
• less severe
• Hx of PAD, past vascular interventions
• Cardiac Hx unlikely
• cyanotic, less cold
• hard calcified artery
• absent contralateral leg pulse

Embolus

• sudden onset
• severe
• Hx of PAD, past vascular interventions unlikely
• Hx of AF, MI
• cold, mottled
• soft, tender artery
• contralateral leg pulse found

Question 7

Management of critical limb ischemia

• conservative
• surgical

Answer 7

Pain management - move up WHO pain ladder
-laxatives, antiemetics for opiate SE

Surgical - revascularisation, amputation

Question 8

Management of acute limb ischemia

• initial
• conservative
• surgical

Answer 8

IRREVERSIBLE TISSUE DAMAGE IN 6HRS
Initial
-high flow O2
-heparin

Conservative - prolonged heparin

Surgical - embolic cause
-embolectomy
Surgical - thrombotic cause
-thrombolysis

Non viable => amputation

Question 9

Complications of ALI

Answer 9

Reperfusion injury

• massive edema => compartment syndrome, hypovolemic shock
• sudden release of K, H => hyperkalemia, acidosis