Peripheral Vascular Conditions

Question 1

What is Intermittent Claudication?

Answer 1

= pain in limb brought on by exertion, relieved at rest, and reoccurs on similar effort

Usually measured by how far someone can walk on flat

Question 2

What is critical limb ischaemia?

Answer 2

= pain at rest +/- tissue loss

<50mmHg at ankle

Question 3

How is CLI managed?

Answer 3

Stop smoking 
Exercise more
Good diet 
Lose weight 
Diabetes control —> reduce HbA1c by 1-21%

Question 4

What is the mortality and morbidity rate of CLI?

Answer 4

25% amputation rate

50% of which die within 5 years

Question 5

What medications might you prescribe to treat IC or CLI?

Answer 5

Statins - simvastatin 40mg (HDL protective + 24% revascularisation)

Antiplatelets - aspirin or clopidogrel 75mg

Anti hypertensives
Antioxidants - omega 3

Cilostazol/Pletal - phosphodiesterase inhibitor

Question 6

How can CLI be treated with angioplasty? What are the benefits and risk factors?

Answer 6

Angioplasty =
use balloon +/- stent

Good: minimally invasive, short stay, quick recovery
Bad: failure to dilate, re-stenosis, amputation, death

Question 7

When is a surgical bypass used to treat CLI? What are the risks and benefits?

Answer 7

= conduit
Can be autologous - femoral vein
Or synthetic - PFTE/Dacron

Reserved for patients with CLI +/- life altering claudication

Good: save limb, retain independence, wound healing, don’t need multiple visits
Bad: graft failure, MI, infection, limb loss, death

Question 8

What are varicose veins?

Answer 8

Diseased valves or refluxing valves —> blood flows back —> vein stretches —> back pressure —> varicose veins

Question 9

What are the symptoms of varicose veins?

Answer 9

Dilated, tortuous, incompetence, reflux = aching veins

Hypertension in veins

Swelling of ankles

Question 10

What are some complications of varicose veins?

Answer 10

Swelling
Discomfort
Itching 
Haemosiderin 
Eczema 
Lipodermatosclerosis 
Ulceration 
Thrombophlebitis

Question 11

How are varicose veins managed?

Answer 11

Conservative:
Leg elevation
Compression stockings
Activity

Medical:
Topical relief

Surgery:
Open ligation + stripping
Foam scleropathy
Endovenous solutions

Question 12

What is chronic limb ischaemia?

Answer 12

pain at rest +/- tissue loss

<50mmHg at ankle

Question 13

What is the ABPI? What are its classifications?

Answer 13

>1.4 = calcification might be present
>1 = likely normal
0.8 - 1 = no significant disease
0.5 - 0.8 = moderate disease
0.3 - 0.5 = severe disease
<0.3 = critical ishaemia

Question 14

What is Buerger’s test?

Answer 14

The vascular angle, which is also called Buerger’s angle, is the angle to which the leg has to be raised before it becomes pale, whilst lying down.
In a limb with a normal circulation the toes and sole of the foot, stay pink, even when the limb is raised by 90 degrees.
In an ischaemic leg, elevation to 15 degrees or 30 degrees for 30 to 60 seconds may cause pallor.
A vascular angle of less than 20 degrees indicates severe ischaemia.

Question 15

When is surgery considered as a treatment for limb ischaemia? When might amputation be considered?

Answer 15

bypass graft if chronic limb ischaemia +/- life-altering claudication
amputation is considered when there is tissue loss/death or claudication persists despite bypass graft

Question 16

What medication could be involved in palliative care of intractable limb ischaemia?

Answer 16

opiates
gabapentin
antidepressants

Question 17

When is an amputee’s stitches removed post-op?

Answer 17

after 10-21 days

Question 18

What are the 6 signs of Acute Limb Ischaemia?

Answer 18

Pain
Pallor
Pulselessness
Polar
Paralysis
Paresthesia

Question 19

How can limb ischaemia cause AKI?

Answer 19

ischaemia –> increased lactate –> rhabdomyolysis –> AKI

Question 20

What is reperfusion syndrome?

Answer 20

tissue damage caused when blood supply returns to tissue after a period of ischemia.
The absence of oxygen and nutrients from blood during the ischemic period creates a condition in which the restoration of circulation results in inflammation and oxidative damage through the induction of oxidative stress.

treat with prophylactic fasciotomy

Question 21

What are the common causes of leg ulcers? What are the different types?

Answer 21

chronic venous hypertension - venous
ischaemia - arterial
diabetes - diabetic ulcer
prolonged soft tissue compression - pressure sore/decubitus ulcer

Question 22

How do you treat leg ulcers?

Answer 22

primary = treat cause

secondary
compression stockings
elevate legs above heart
vitamin supplement if needed
review medication