Peripheral artery disease

Question 1

What is PAD?

Answer 1

Narrowing of the arteries that supply the limbs and periphery, which reduces the blood flow to some of these areas

Question 2

What is intermittent claudication?

Answer 2

Symptom of ischaemia in a limb that occurs during exertion and is relieved by rest. It’s typically a crampy, achy pain most commonly in the calf but can also occur in the thigh and buttock muscles

Question 3

1) What is critical limb ischaemia?
2) Name 2 features of critical limb ischaemia
3) What are the 6Ps of critical limb ischaemia features?

Answer 3

1) End stage of PAD where an inadequate blood supply to a limb means it can’t function normally
2) Pain occurs at rest, is non healing, is associated with ulcers and gangrene, typically causes a burning pain that’s worse at night when the leg is raised
3) Pain, pallor, pulseless, paralysis, paraesthesia (pins and needles) and perishing cold

Question 4

What is acute limb ischaemia?

Answer 4

Rapid onset of ischaemia in a limb typically due to a thrombus occluding the arterial supply to a distal limb

Question 5

1) What causes Leriche syndrome?
2) What is the clinical triad associated with Leriche syndrome?

Answer 5

1) Occlusion of the distal aorta/proximal iliac artery
2) Thigh/buttock claudication, absent femoral pulses, male impotence

Question 6

What is the difference between necrosis and gangrene?

Answer 6

Necrosis refers to tissue death whereas gangrene refers to tissue death specifically due to inadequate blood supply

Question 7

1) Name 2 signs of PAD on inspection
2) What is dependent rubor?
3) Name 2 signs of PAD on examination

Answer 7

1) Skin pallor, cyanosis, muscle wasting, hair loss, ulcers and poor wound healing, gangrene, dependent rubor
2) Deep red colour when limb is lower than the rest of the body
3) Reduced skin temperature and sensation., prolonged capillary refill time, weaker peripheral pulses and signs of CVD

Question 8

1) What causes an arterial ulcer?
2) What causes a venous ulcer
3) Name 2 features of arterial ulcers
4) Name 2 features of venous ulcers

Answer 8

1) Caused by ischaemia secondary to inadequate blood supply
2) Caused by impaired drainage and pooling of blood in the legs
3) Smaller and deeper than venous ulcers,
well defined borders, punched out appearance, occur peripherally, reduced bleeding, painful
4) Occurs after a minor injury to the leg, larger than arterial ulcers, more superficial than arterial ulcers, irregular and gently sloping borders, affect the gaiter area of the leg, less painful than arterial ulcers, occurs with other signs of chronic venous insufficiency

Question 9

Investigations
1) What is an ankle-brachial pressure index?
2) What is a duplex ultrasound?
3) What is the gold standard investigation?
4) Name another imaging modality used?

Answer 9

1) Ratio of systolic blood pressure in the ankle compared with the systolic blood pressure in the arm
2) Ultrasound that shows the speed and volume of blood flow
3) Duplex ultrasound
4) Angiography - CT or MRI

Question 10

1) Name a risk factor management that can be implemented
2) Name a way claudication can be managed medically

Answer 10

1) Smoking cessation, treatment of hypertension and high cholesterol, antiplatelet therapy (clopidogrel 1st line)
2) Supervised exercise programmes, peripheral vasodilators i.e. naftidrofuryl oxalate

Question 11

Surgical management of PAD
1) When is percutaneous transluminal angioplasty used?
2) Name a surgical reconstruction that can be done to treat PAD
3) When is limb amputation considered?

Answer 11

1) When disease is located to 1 segment of an artery
2) Arterial reconstruction with a bypass graft, femoral-popliteal bypass graft, femoral-femoral crossover
3) When restoring blood flow is not possible