Peripheral Vascular Disease

Question 1

What is peripheral vascular disease?

Answer 1

a chronic condition due to atherosclerosis of arteries in the limbs. The level of arterial occlusion present is proportional to the symptoms.

Question 2

How does PVD classically present?

Answer 2

peripheral vascular disease presents as pain in the lower limbs which is brought on by exertion (typically the patient will be able to walk a specific distance before the pain comes on) and the pain is relieved by rest.

Question 3

What two major arteries does peripheral vascular disease most commonly affect?

Answer 3

1. Aorto-iliac artery
2. Infra-inguinal artery

Question 4

What is the epidemiology of PVD?

Answer 4

affects about 10-15%

Question 5

Give 4 risk factors for chronic limb ischaemia:

Answer 5

1) smoking
2) diabetes
3) hypercholesterolaemia
4) hypertension

Question 6

What system is used to classify the stages of chronic limb ischaemia?

Answer 6

Fontaine Classification

Question 7

List and describe the four Fontaine stages of chronic limb ischaemia:

Answer 7

1) stage 1: asymptomatic
2) stage 2: intermittent claudication
3) stage 3: pain at rest
4) stage 4: necrosis/ gangrene

Question 8

What is claudication?

Answer 8

Pain that occurs in the extremities due to limited blood flow and resultant tissue hypoxia in the leg - exacerbated by exercise

Question 9

Where is claudication associated with chronic limb ischaemia most commonly experienced?

Answer 9

Calf

Question 10

List 4 consequences of claudication associated with aorto-iliac disease:

Answer 10

1) pain in buttock
2) pain in hip
3) pain in thigh
4) erectile dysfunction

Question 11

What is spinal claudication?

Answer 11

y impingement of the caudal equina by a spinal stenosis. This also classically causes pain in the back of the legs on exertion.

Question 12

What is Beuger’s angle?

Answer 12

the leg will go pale and cold upon raising it 20’ off the couch.

Question 13

Give 7 signs of chronic limb ischaemia:

Answer 13

1) cold limbs
2) ulceration
3) dry skin
4) increased capillary refill time
5) lack of hair on limbs
6) discolouration
7) diminished/ absent pulses

Question 14

Give 2 potential differentials for chronic limb ischaemia symptoms:

Answer 14

1. popliteal artery entrapment
2. peripheral neuropathy

Question 15

What does ABPI stand for?

Answer 15

ankle brachial pressure index

Question 16

What is ABPI?

Answer 16

a measurement of the cuff pressure at which blood flow is detectable by Doppler in the posterior tibial or arterial tibial artery compared to pressure in the brachial artery

Question 17

What does an ABPI less than 0.9 indicate?

Answer 17

some degree of peripheral vascular disease

Question 18

What disease is associated with an ABPI of less than 0.5?

Answer 18

critical limb ischaemia

Question 19

Give 3 imaging techniques used to diagnose chronic limb ischaemia:

Answer 19

1) Duplex ultrasound (FIRST LINE)
2) contrast-enhanced MR angiography
3) CT angiography

Question 20

Give 3 management techniques for chronic limb ischaemia:

Answer 20

1. Risk factor management e.g. statins, antiplatelets, diet
2. exercise plan
3. consider giving naftidrofuryl oxalate

Question 21

Describe how naftidrofuryl oxalate can treat chronic limb ischaemia:

Answer 21

it is a vasodilator that inhibits the 5-HT2 receptors and can reduce lactic acid levels

Question 22

Name 3 potential surgical interventions for critical limb ischaemia:

Answer 22

1. angioplasty and stenting
2. Bypass surgery
3. Amputation

Question 23

When is amputation considered?

Answer 23

if the ischaemia is severe with unreconstructible arterial disease

Question 24

What is critical limb ischaemia?

Answer 24

the end stage of peripheral artery disease where there is an inadequate supply of blood to the limb to allow it to function at rest

Question 25

How does critical limb ischaemia present? (3)

Answer 25

1. Gangrene
2. non-healing ulcers
3. pain at rest

Question 26

Give the 6ps of acute limb ischaemia:

Answer 26

1) pain
2) pallor
3) pulseless
4) paralysis
5) paraesthesia (pins and needles)
6) perishingly cold

Question 27

Give the two main causes of acute limb ischaemia:

Answer 27

1) thrombosis
2) emboli

Question 28

What is the most common form of investigation for acute limb ischaemia?

Answer 28

Duplex ultrasound

Question 29

Give 5 potential surgical interventions for acute limb ischaemia:

Answer 29

1) endovascular thrombolysis
2) surgical thrombectomy
3) endarterectomy
4) bypass surgery
5) amputation

Question 30

What is surgical thrombectomy?

Answer 30

cutting open the affected vessels and removing the thrombus

Question 31

What is endarterectomy?

Answer 31

surgical removal of fatty deposits

Question 32

Give the two steps of Buerger’s Test:

Answer 32

1) have patient lie on their back and lift their legs to an angle of 45 degrees at the hip and hold them there for 1-2 mins, looking for pallor
2) sit the patient up with their legs hanging over the side of the bed so blood will flow back into the legs - in PAD, the limb will initially turn BLUE followed by DARK RED due to vasodilation

Question 33

What is Buerger’s disease?

Answer 33

Occlusion of the small vessels of the hands and feet seen in young men who smoke and can lead to gangrene and amputation

Question 34

What is Leriche syndrome?

Answer 34

a clinical triad caused by occlusion in the distal aorta or proximal common iliac artery

1) thigh/ buttock claudication
2) absent femoral pulse
3) erectile dysfunction

Question 35

What is the most common form of investigation for acute limb ischaemia?

Answer 35

Duplex ultrasound

Question 36

What is endovascular thrombolysis?

Answer 36

inserting a catheter through the arterial system to apply thrombolysis directly into the clot