Peripheral Vascular Disease

Question 1

What is peripheral vascular disease characterized by?

Answer 1

Answer: is characterized by
narrowing, and in the final stages, occlusion of the peripheral arteries due to atherosclerotic plaques.
It most commonly affects the legs.

Question 2

What are the common risk factors for peripheral vascular disease?

Answer 2

Answer: include
* smoking,
* diabetes,
* hypercholesterolemia, and
* hypertension.

Question 3

What is intermittent claudication?

Answer 3

Answer:
* is a symptom of peripheral vascular disease.
* It occurs when there is insufficient blood flow to exercising muscles due to atherosclerosis in the arteries.
* The classic presentation is exertional discomfort, most commonly in the calves, which is relieved by rest.

Question 4

What are the clinical features of severe peripheral vascular disease or critical limb ischemia?

Answer 4

Answer: include
* pain at rest,
* ulceration,
* tissue necrosis,
* diminished or absent peripheral pulses, and
* poor tissue nutrition (lack of hair, thick nails, shiny skin).

Question 5

What is ABPI?

Answer 5

Answer:
* ABPI stands for ankle-brachial pressure index.
* It is a measurement used to assess peripheral arterial disease.
* It is calculated by dividing the ankle pressure by the brachial pressure.

Question 6

What are the normal ABPI ranges and what do they indicate?

Answer 6

Answer:
* **The normal ABPI range is 0.9 - 1.2.
* **
* A value below 0.9 suggests peripheral arterial disease, while a
* value above 1.2 may indicate calcified vessels or arterial stiffness.

Question 7

What imaging techniques are used if revascularization is being considered?

Answer 7

Answer: include
* duplex ultrasound,
* CT/MRI, and
* catheter angiography.

Question 8

What are the management strategies for peripheral vascular disease?

Answer 8

Answer: include
* lifestyle changes such as smoking cessation, a supervised exercise program, and weight loss.
* Control of risk factors such as diabetes and hypertension is important. Other interventions may include
* angioplasty or bypass grafting in severe cases, vasodilator therapy (naftidrofuryl oxalate) for patients reluctant to undergo interventional treatment, and
* amputation in cases of severe critical limb ischemia.

Question 9

What is intermittent claudication?

Answer 9

Answer:
* is a symptom of ischaemia in a limb.
* It is characterized by crampy, achy pain in the calf, thigh, or buttock muscles that occurs during exertion and is relieved by rest.
* It is associated with muscle fatigue when walking beyond a certain intensity.

Question 10

What is critical limb ischaemia?

Answer 10

Answer:
* is the end-stage of peripheral arterial disease.
* It refers to an inadequate blood supply to a limb at rest.
* The features include pain at rest, non-healing ulcers, and gangrene.
* There is a high risk of limb loss in this condition.

Question 11

What is acute limb ischaemia?

Answer 11

Answer:
is a condition characterized by a sudden onset of ischaemia in a limb.
It is typically caused by a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.

Question 12

What is necrosis?

Answer 12

Answer: Necrosis refers to the death of tissue.

Question 13

What is gangrene?

Answer 13

Answer:
refers to the death of tissue specifically due to an inadequate blood supply.
It is a severe form of tissue necrosis.

Question 14

What is atherosclerosis?

Answer 14

Answer:
* is the combination of atheromas (fatty deposits in the artery walls) and sclerosis (hardening or stiffening of the blood vessel walls).
* It is a process that affects medium and large arteries, caused by chronic inflammation and immune system activation in the artery wall.
* Lipids are deposited in the artery wall, leading to the development of fibrous atheromatous plaques.

Question 15

What are the modifiable risk factors for atherosclerosis?

Answer 15

Answer: Modifiable risk factors for atherosclerosis include (controllable stuff )
smoking,
alcohol consumption,
poor diet (high in sugar and trans-fat, low in fruits, vegetables, and omega-3s),
low exercise or sedentary lifestyle, obesity, poor sleep, and stress.

Question 16

What are the non-modifiable risk factors for atherosclerosis?

Answer 16

• Answer: Non-modifiable risk factors for atherosclerosis include (uncontrolled )
• older age,
• family history of atherosclerosis, and
• being male.

Question 17

How do medical co-morbidities contribute to the risk of atherosclerosis?

Answer 17

Answer: Medical co-morbidities increase the risk of atherosclerosis. Conditions such as
diabetes,
hypertension,
chronic kidney disease,
inflammatory conditions (e.g., rheumatoid arthritis), and the use of
atypical antipsychotic medications can contribute to a higher risk of developing atherosclerosis.

Question 18

What is the characteristic symptom of peripheral arterial disease?

Answer 18

Answer:
is intermittent claudication, which is described as crampy pain that occurs predictably after walking a certain distance. The pain subsides with rest.

Question 19

What are the features of critical limb ischaemia according to the “6 P’s” mnemonic?

Answer 19

Answer:

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

6 P’s – if present need to be sorted in 4-6hrs to save the limb

Question 20

What type of pain is typically associated with critical limb ischaemia?

Answer 20

Answer: Critical limb ischaemia typically causes **burning pain. **
The pain is worse at night when the leg is raised, as gravity no longer helps pull blood into the foot.

Question 21

What is Leriche syndrome?

Answer 21

Answer:
* occurs with occlusion in the distal aorta or proximal common iliac artery.
It is characterized by a
* clinical triad of thigh/buttock claudication,
* absent femoral pulses, and male impotence.

Question 22

What are some signs to look for during examination in peripheral arterial disease?

Answer 22

Answer:
* include risk factors such as
* tar staining on the fingers and xanthomata (yellow cholesterol deposits on the skin).
* Signs of cardiovascular disease may be present, such as missing limbs or digits after previous amputations, midline sternotomy scar (previous coronary artery bypass grafting), a scar on the inner calf for saphenous vein harvesting (previous coronary artery bypass grafting), and focal weakness suggestive of a previous stroke. Palpation of peripheral pulses should be performed, including radial, brachial, carotid, abdominal aorta, femoral, popliteal, posterior tibial, and dorsalis pedis pulses.
* Using a hand-held Doppler can assist in accurately assessing pulses when they are difficult to palpate.
* Signs of arterial disease on inspection may include skin pallor, cyanosis, dependent rubor, muscle wasting, hair loss, ulcers, poor wound healing, and gangrene.
* Other findings may include reduced skin temperature, reduced sensation, prolonged capillary refill time, and changes during Buerger’s test.

Question 23

What is the purpose of using a hand-held Doppler during examination?

Answer 23

Answer: A hand-held Doppler is used during examination to accurately assess peripheral pulses when they are difficult to palpate.

Question 24

What are some signs of arterial disease on inspection?

Answer 24

Answer:
Signs of arterial disease on inspection may include skin pallor, cyanosis, dependent rubor (a deep red color when the limb is lower than the rest of the body),
muscle wasting, hair loss, ulcers, poor wound healing, and gangrene (breakdown of the skin with a dark red/black change in coloration).

Question 25

What is the purpose of Buerger’s test in assessing peripheral arterial disease?

Answer 25

Answer:
* is used to assess peripheral arterial disease in the leg.
* It helps evaluate the adequacy of arterial blood supply by observing the presence of pallor when the legs are lifted to a certain angle and the color changes (blue and dark red) when the legs are allowed to hang over the side of the bed.

Question 26

How can arterial and venous ulcers be distinguished from each other?

Answer 26

Answer: Arterial ulcers and venous ulcers can be distinguished based on the following features:
1. Arterial ulcers are smaller and deeper than venous ulcers.
2. Arterial ulcers have well-defined borders and a “punched-out” appearance, while venous ulcers have irregular, gently sloping borders.
3. Arterial ulcers occur peripherally, such as on the toes, while venous ulcers commonly affect the gaiter area of the leg (mid-calf down to the ankle).
4. Arterial ulcers have reduced bleeding and are typically painful, while venous ulcers are less painful.
5. Arterial ulcers are caused by ischaemia due to inadequate blood supply, whereas venous ulcers are caused by impaired drainage and pooling of blood in the legs.
6. Arterial ulcers may be associated with other signs of arterial insufficiency, such as decreased pulses, whereas venous ulcers may be associated with signs of chronic venous insufficiency, such as haemosiderin staining and venous eczema.

Question 27

nvestigations for peripheral arterial disease include:

Answer 27

1. Ankle-brachial pressure index (ABPI):
   ABPI is the ratio of systolic blood pressure (SBP) in the ankle compared to the SBP in the arm. It is measured using a Doppler probe. ABPI values can indicate the severity of peripheral arterial disease.
2. Duplex ultrasound: This test uses ultrasound to assess the speed and volume of blood flow in the arteries.
3. Angiography: Angiography, performed using CT or MRI, involves the use of contrast to visualize the arterial circulation and identify any blockages or stenosis.

Question 28

Management of Intermittent Claudication

Answer 28

Lifestyle changes

Exercise training
Medicaltreatments:
- Atorvastatin 80mg
- Clopidogrel 75mg once daily (aspirin if clopidogrel is unsuitable)
- Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)

Surgicaloptions:

• Endovascular angioplasty and stenting
• Endarterectomy– cutting the vessel open and removing the atheromatous plaque
• Bypass surgery– using a graft to bypass the blockage

Question 29

Management of Critical Limb Ischaemia

Answer 29

Patients with critical limb ischaemia require urgent referral to the vascular team.
They require analgesia to manage the pain.

Urgent revascularisation can be achieved by:

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

Question 30

Management of Acute Limb Ischaemia

Answer 30

Patients with acute limb ischaemia need an urgent referral to the on-call vascular team for assessment.

Management options include:

• Endovascular thrombolysis– inserting a catheter through the arterial system to apply thrombolysis directly into the clot
• Endovascular thrombectomy– inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices
• Surgical thrombectomy– cutting open the vessel and removing the thrombus
• Endarterectomy
• Bypass surgery
• Amputationof the limb if it is not possible to restore the blood supply

Question 31

Q: Which vessels are primarily affected in peripheral artery disease (PAD)?

Answer 31

A: The lower extremity vessels are more commonly affected, including the aorta, iliac, femoral, popliteal, tibial, and pedal vessels.

Question 32

Q: What happens to the tissues when there is reduced blood flow in PAD?

Answer 32

A: When blood flow is reduced, tissues in the affected area receive less oxygen and nutrients, leading to ischemia (lack of blood supply) in the muscles and skin.

Question 33

Q: What can occur if a large plaque obstructs the blood flow in a vessel affected by PAD?

Answer 33

A: If a large plaque obstructs the blood flow, the tissues beyond that point become more susceptible to reduced oxygen and nutrient delivery, increasing the risk of ischemia.

Question 34

Q: How does increased physical activity worsen the condition in PAD?

Answer 34

A:
* Increased physical activity, such as walking or exertional activities
,
* increases the oxygen demand of the muscles. In PAD, where there is already reduced oxygen supply,

• this imbalance between demand and supply worsens ischemia and can lead to further complications.

Question 35

Q: What can happen if ischemia is not addressed over a prolonged period of time in PAD?

Answer 35

A: If ischemia persists without intervention, it can progress to the death of the affected tissue, resulting in tissue infarction (cell death due to lack of blood supply).

Question 36

Q: What are the two main causes of reduced oxygen (O2) supply in peripheral artery disease (PAD)?

Answer 36

A: The two main causes are thrombosis and embolism.

Question 37

Q: What is the difference between thrombosis and embolism in relation to PAD?

Answer 37

A:

• Thrombosis is the chronic type of PAD that progresses gradually, while
• embolism is an acute issue where a clot dislodges and blocks a vessel suddenly.

Question 38

Q: What are the risk factors associated with atherosclerosis, the most common cause of thrombosis in PAD?

Answer 38

A: hypertension, high LDL (low-density lipoprotein) or low HDL (high-density lipoprotein), smoking, diabetes mellitus, and old age.

Question 39

Q: How can stent thrombosis occur in PAD?

Answer 39

A: Stent thrombosis can occur if a patient with PAD, who has undergone stent placement, does not comply with the prescribed medications such as aspirin and Plavix (Clopidogrel).

Non-compliance increases the risk of thrombosis within the stent.

Question 40

Q: What are some causes of embolic PAD?

Answer 40

A: Causes of embolic PAD include atrial fibrillation, left ventricular thrombus (due to myocardial infarction or left heart failure), abdominal aortic aneurysm (AAA), popliteal aneurysm, vasculitis (inflammation of the vessels), trauma, and compartment syndrome.

Question 41

Q: How can an embolus from an abdominal aortic aneurysm or popliteal aneurysm lead to reduced oxygen supply in PAD?

Answer 41

A: If a piece of a clot breaks off from an abdominal aortic aneurysm or popliteal aneurysm, it can become lodged in a vessel downstream, causing decreased oxygen and nutrient supply distal to the clot.

Question 42

Q: What is compartment syndrome in relation to reduced perfusion in PAD?

Answer 42

A: Compartment syndrome refers to the compression of vessels, leading to reduced perfusion in the affected area.

Question 43

Q: How does reduced blood flow due to plaques or clots in the vessels affect the muscles in peripheral artery disease (PAD)?

Answer 43

A: Reduced blood flow to the muscles in PAD leads to insufficient oxygen and nutrient supply, resulting in muscle pain.

Question 44

Q: What is the significance of pain location in PAD?

Answer 44

A: The location of pain can indicate which vessels may have plaques or be occluded. It helps in identifying the affected areas and potential complications.

Question 45

Q: If a plaque or embolus is present in the iliac artery, what symptoms may be experienced?

Answer 45

A: Patients may experience pain in the hip and buttocks region, which can radiate down the entire extremity.

Diminished femoral, popliteal, and pedal pulses may also be observed.

Erectile dysfunction may occur due to compromised genital artery blood flow.

Question 46

Q: If a clot is lodged in the thigh area, which vessels are likely affected in PAD?

Answer 46

A: The femoral and popliteal arteries are affected. This can cause calf pain and compromise blood flow to the calves.

Question 47

Q: What can cause foot pain in PAD?

Answer 47

A: Plaques developing in the calves can lead to reduced blood flow to the foot, resulting in foot pain.

Question 48

Q: How would you describe the nature of pain in PAD?

Answer 48

A: The pain in PAD is often described as claudication pain, which is pain that occurs due to vascular issues.

Question 49

Q: Why does pain worsen with exertion in PAD?

Answer 49

A: Exertion increases the oxygen demand of the muscles.
In PAD, where there is already reduced oxygen supply, the combination of increased demand and inadequate supply leads to ischemia and worsens the pain.

Question 50

Q: How does pain in PAD change with rest?

Answer 50

A:
Resting can decrease the demand for oxygen, leading to an improvement in pain.

If pain worsens with exertion but improves during rest, it indicates that the blood supply is suboptimal but sufficient for resting conditions.

Question 51

Q: What does it indicate if the pain in peripheral artery disease (PAD) occurs at rest?

Answer 51

A: If pain occurs at rest in PAD, it indicates that the blood supply to the affected area is extremely low. Even without an increase in oxygen demand, the pain worsens due to severe ischemia.

Question 52

Q: What is Buerger’s sign in relation to resting claudication?

Answer 52

A: Buerger’s sign refers to the change in color and increased pain in the legs when they are elevated.

It occurs because the blood flow is working against gravity.

If the pain improves when the legs hang down, it is a sign of resting claudication.

Question 53

Q: What is critical limb ischemia?

Answer 53

A: Critical limb ischemia occurs when there is a severe reduction in blood supply to the limb, posing a threat to its viability.

It is characterized by rest pain persisting for more than two weeks, arterial ulcers, or gangrene.

Question 54

Q: How does critical limb ischemia differ from claudication pain?

Answer 54

A: Critical limb ischemia indicates a severe reduction in oxygen supply to the limb, with a risk of infarction.

In contrast, claudication pain is related to exercise and is relieved with rest.

Question 55

Q: How can the presence of plaque or embolus affect pulses in PAD?

Answer 55

A: Plaque or embolus occluding the blood flow can result in reduced or absent pulses distal to the affected area.

Question 56

Q: What are bruits, and why are they increased in PAD?

Answer 56

A: Bruits are abnormal sounds caused by turbulent blood flow.

In PAD, the presence of plaque or embolus increases the turbulence of blood flow, leading to increased bruits that can be auscultated.

Question 57

Q: How does reduced oxygen supply in PAD affect muscle function?

Answer 57

A: Reduced oxygen supply in PAD leads to decreased ATP production in muscles, resulting in impaired muscle contraction. Over time, this can lead to muscle atrophy.

Question 58

Q: Why does muscle atrophy occur in PAD?

Answer 58

A: Muscle atrophy occurs in PAD due to the decreased oxygen supply, which hampers ATP production necessary for muscle contraction.

The muscles become weaker and may shrink in size over time.

Question 59

Q: What are the early skin manifestations of peripheral artery disease (PAD)?

Answer 59

A: pale and cold extremities, hair loss, thin skin, and thin nails.

Question 60

Q: How does decreased blood flow in PAD affect the color and temperature of the skin?

Answer 60

A: Decreased blood flow in PAD leads to pale skin due to reduced oxygen supply.

The skin also becomes colder because blood carries heat, and decreased blood flow results in less heat reaching the skin.

Question 61

Q: Why does hair loss occur in PAD?

Answer 61

A: Hair loss occurs in PAD due to the decreased oxygen and nutrient supply to the hair follicles.

Inadequate blood flow can disrupt normal hair growth and result in hair loss.

Question 62

Q: What causes thinning of the skin and nails in PAD?

Answer 62

A: is caused by the insufficient oxygen and nutrient supply to the tissues, which affects their ability to regenerate and maintain normal thickness.

Question 63

Q: What are arterial ulcers, and how do they differ from venous ulcers?

Answer 63

A:

• Arterial ulcers are ulcers that develop due to impaired blood flow in arteries.
• They are typically punched out, dry, and located on pressure points such as toes or lateral malleolus.
• Arterial ulcers differ from venous ulcers in their appearance and location.

Question 64

Q: What is the progression from dry gangrene to wet gangrene in PAD?

Answer 64

A:
* Dry gangrene is characterized by black discoloration and a lack of erythema or exudate.

• If the condition worsens, it can progress to wet gangrene, which involves erythema, infection, exudate, and further black discoloration.
• Wet gangrene is a severe condition that can lead to sepsis if not treated promptly.

Question 65

Q: How do the skin manifestations progress in severity in PAD?

Answer 65

A:
progress from decreased color (pallor), cold extremities, and reduced hair to thin skin, thin nails, arterial ulcers, dry gangrene, and, in severe cases, wet gangrene.

These manifestations represent the worsening effects of inadequate oxygen supply to the tissues.

Question 66

Q: What are the common causes of acute limb ischemia?

Answer 66

A: The common causes of acute limb ischemia are embolus (most common), thrombus, and compression of the blood vessel due to trauma or conditions like compartment syndrome.

Question 67

Q: What are the clinical manifestations of acute limb ischemia?

Answer 67

A: are often referred to as the 6P’s:

Pain (severe and out of proportion)
Paralysis (muscle weakness or even paralysis)
Pallor (pale skin due to inadequate blood supply)
Poikilothermal (inability to regulate skin temperature)
Paresthesia (abnormal sensations due to nerve involvement)
Pulseless (absence of pulse distal to the occlusion)

Question 68

Q: What does it mean if a limb is considered viable in acute limb ischemia?

Answer 68

A: If a limb is considered viable, it means that there is no muscle weakness, minimal pain, no sensory loss, and positive Doppler pulses.

Revascularization can potentially save the limb in this case.

Question 69

Q: What does it mean if a limb is considered threatened in acute limb ischemia?

Answer 69

A: If a limb is considered threatened, it means that immediate revascularization is required to prevent limb loss.

Signs of weakness, pain, sensory loss, and absent or reduced Doppler pulses indicate a threatened limb.

Question 70

Q: What does it mean if a limb is considered nonviable in acute limb ischemia?

Answer 70

A: If a limb is considered nonviable, it means that the tissue has already suffered irreversible damage.

Signs include paralysis, absence of pain (due to nerve destruction), loss of sensations, and absent pulses in Doppler examination.

In such cases, amputation may be necessary.

Question 71

Q: What is the ankle-brachial index (ABI) and its significance in diagnosing peripheral artery disease (PAD)?

Answer 71

A: The ankle-brachial index (ABI) is a first-line diagnostic test for PAD.

It involves comparing the blood pressure in the ankle to that in the brachial artery. A lower ABI indicates more severe PAD. Values ≤0.9 are diagnostic of PAD.

Question 72

Q: What are the indications for using CT/MRA in diagnosing PAD?

Answer 72

A: CT (computed tomography) or MRA (magnetic resonance angiography) is used in patients with acute limb ischemia or critical limb ischemia to assess candidacy for revascularization.

Contrast is used to visualize the blood vessels and determine the extent of the occlusion.

Question 73

Q: What is the role of duplex ultrasound in diagnosing PAD?

Answer 73

A: Duplex ultrasound is a non-invasive alternative to CT/MRA. It is a simple bedside test that can be used when there are contraindications to contrast. It can show occlusions and increased velocities in the blood flow.

Question 74

Q: What is the gold standard for diagnosing PAD?

Answer 74

A: Digital subtraction angiography (DSA) is considered the gold standard for diagnosing PAD.

It is an invasive procedure where a catheter is used to inject contrast, allowing real-time visualization of the blood vessels and identification of stenosis.

Question 75

Q: What is neurogenic claudication, and how does it differ from PAD?

Answer 75

A:

• is a differential diagnosis for PAD and is caused by spinal stenosis.
• It results in exertional calf pain due to compression of nerve roots.
• Differentiating features include postural low back pain (worsened by extension, relieved by flexion),
• decreased or absent deep tendon reflexes (DTR), normal pulses or bruits, and normal skin findings (no thin skin, cold skin, thin nails, thin hair, ulcers, or gangrene).