Peripheral vascular disease

Question 1

What is PVD?

Answer 1

narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas

Question 2

What is intermittent claudication?

Answer 2

Symptom of PVD, crampy pain in lower limbs and buttocks when walking a certain distance

Question 3

Critical limb ischaemia is the end stage of PVD what are the features of it?

Answer 3

Pain
Pallor
Pulseless
Paralysis
Paraesthesia (abnormal sensation or “pins and needles”)
Perishing cold

Question 4

What is Leriche syndrome?

Answer 4

occlusion in the distal aorta or proximal common iliac artery. There is a clinical triad of:

Thigh/buttock claudication
Absent femoral pulses
Male impotence

Question 5

What do you see when examining for PVD?

Answer 5

-Tar staining on the fingers
Xanthomata (yellow cholesterol deposits on the skin)

-Looks for signs of cardiovascular disease:
Missing limbs or digits after previous amputations
Midline sternotomy scar (previous CABG)
A scar on the inner calf for saphenous vein harvesting (previous CABG)
Focal weakness suggestive of a previous stroke

• Weak peripheral pulses

Question 6

What are signs of arterial disease on examination?

Answer 6

Skin pallor
Cyanosis
Dependent rubor (a deep red colour when the limb is lower than the rest of the body)
Muscle wasting
Hair loss
Ulcers
Poor wound healing
Gangrene

On examination, there may be:

Reduced skin temperature
Reduce sensation
Prolonged capillary refill time (more than 2 seconds)
Changes during Buerger’s test

Question 7

What is Buerger’s test?

Answer 7

assess for peripheral arterial disease in the leg
-patient supine, legs at 45 degree angle hold there for 1-2 mins and look at pallor- means arterial supply is not adequate to overcome gravity.
- sit patient up with legs hanging over the side of the bed - legs go blue initially and then dark red (rubor)

Question 8

How do arterial ulcers differ from venous ulcers?

Answer 8

Arterial ulcers- caused by ischaemia secondary to an inadequate blood supply.
smaller than venous
deeper than venous
well defined borders
are painful
have reduced bleeding

Question 9

What do venous ulcers typically look like?

Answer 9

occur after minor injury to leg
larger than arterial
more superficial than arterial ulcers
irregular, gently sloping borders
less painful than arterial ulcers

Question 10

How do you investigate PVD?

Answer 10

Ankle-branchial pressure index
duplex ultrasound - shows the speed and volume of blood flow
angiography- using contrast to highlight the arterial circulation

Question 11

How do we manage intermittent claudication?

Answer 11

• lifestyle changes: manage modifiable risk factors
• exercise
• medical: atorvastatin 80mg, clopidogrel 75mg, Naftidrofuryl oxalate, surgical: Endovascular angioplasty and stenting, Endarterectomy, Bypass surgery

Question 12

What does Endovascular angioplasty and stenting involve?

Answer 12

-inserting catheter through the arterial system under x-ray
- balloon inflated at the site of stenosis

Question 13

How do we manage critical limb ischaemia ?

Answer 13

• urgent referral to vascular team + analgesia
  -Urgent revascularisation can be achieved by:

Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply

Question 14

Management of acute limb Ischaemia ?

Answer 14

Endovascular thrombolysis- insert catheter through arterial system
Endovascular thrombectomy- inserting a catheter through arterial system and removing the thrombus by aspiration
Surgical thrombectomy- cutting open the vessel and removing the thrombus
Endarterectomy
Bypass surgery
Amputation- of the limb if it is not possible to restore the blood supply