Peripheral Vascular/Arterial Disease

Question 1

Define peripheral vascular/ arterial disease

Answer 1

Reduced blood supply and ischaemia in the lower limbs as a result of atherosclerosis and thrombosis

Question 2

Describe the pathophysiology of PVD/PAD

Answer 2

• Peripheral Vascular Disease or Peripheral Arterial Disease is where lower limbs receive less blood due to atherosclerosis and thrombosis
• When occlusion occurs, there can be irreversible nerve and muscle damage as well as skin changes where the skin can become gangrenous

Question 3

What are the risk factors for PVD?

Answer 3

Same as angina

Modifiable
- Hypertension
- Hyperglycaemia (DM)
- Smoking
- Alcohol
- Hypercholesterolaemia
- Obesity/inactivity
- Stress

Non-modifiable
- Age
- Sex (men and post-menopausal women)
- Genetic/Family History

Question 4

What are the 3 main ways PVD/PAD presents?

Answer 4

• Intermittent claudication
• Critical limb ischaemia
• Acute limb-threatening ischaemia

Question 5

What is intermittent claudication?

Answer 5

• This is where skeletal muscle is not adequately perfused during exercise which can result in pain on exertion
• This is due to partial lumen occlusion

Question 6

What is Critical Limb Ischaemia?

Answer 6

• An advanced form of chronic limb ischaemia but the occlusion is larger, and the blood supply is barely adequate to meet metabolic demand
• There is pain at rest and risk of infection and skin becoming gangrenous

Question 7

What is Acute Limb-Threatening Ischaemia?

Answer 7

• This is commonly a result of an emboli which causes a sudden decrease in perfusion
• There is total vessel occlusion, and the emboli tend to lodge in bifurcations or a narrowing
• As the name suggests, a limb is at risk

Question 8

What are the symptoms of acute limb-threatening ischaemia?

Answer 8

6 Ps are used to remember the symptoms

Pulselessness
Pallor
Pain
Perishingly Cold
Paralysis
Paraesthesia

However, sometimes symptoms might be masked if the patient already cannot walk or is insensitive to pain

Question 9

What are signs of PVD/PAD?

Answer 9

• Low Ankle Brachial Pressure Index/ABPI (<0.9)
• Skin changes on leg
• Positive Buerger’s Test
• Some of 6 Ps
• Bruit’s: Pulsatile regions due to turbulent blood flow

Question 10

What can you do to diagnose PVD/PAD?

Answer 10

1. Ankle Brachial Pressure Index
2. Duplex Ultrasound Imaging
3. Assess CVR risk

Also Buerger’s test

Question 11

What range of ankle brachial pressure index is normal?

Answer 11

0-8-1.3 is normal

Question 12

What range of ankle brachial pressure index is intermittent claudication?

Answer 12

0.5-0.8 is Intermittent Claudication

Question 13

What range of ankle brachial pressure index is critical limb ischaemia?

Answer 13

<0.5 is Critical Limb Ischaemia

Question 14

What range of ankle brachial pressure index is acute limb threatening ischaemia?

Answer 14

No pulse is Acute Limb Threatening Ischaemia

Question 15

What is duplex ultrasound imaging for in PVD/PAD?

Answer 15

this is to find the location and severity of the stenosis

Question 16

How is CVR risk assessed in PVD/PAD?

Answer 16

with ECG, U+E, FBC and HbA1c

Question 17

What is the Buerger’s test?

Answer 17

• Where you lie a patient flat and then raise their leg to a 45º angle for a minute
• A positive result is if the leg becomes pallor and then becomes perfused when restored to normal position
• The more severe the ischaemia, the lower the angle is needed to induce pallor

Question 18

How do you treat intermittent claudication?

Answer 18

• Manage risk factors via exercise, diet control and smoking cessation
• Medications such as statins and anti-platelets can be used too
• Dire cases can call for revascularisation surgery

Question 19

How do you treat critical limb ischaemia?

Answer 19

• Revascularisation surgery (PCI if small, bypass if large)
• Amputation if severe

Question 20

How do you treat acute limb-threatening ischaemia?

Answer 20

Surgical Emergency, revascularisation is needed within 4-6 hours or else amputation risk is increased

Question 21

What are complications of PVD/PAD?

Answer 21

• Amputation
• Ulceration + gangrene
• Permanent limb weakness
• Infection and poor tissue healing
• Increased risk of cerebrovascular accidents+ CVD