Peripheral vascular disease

Question 1

Define

Answer 1

Range of arterial syndromes caused by oatherosclerotic occlusion

Question 2

Etiology

Answer 2

Most commonly atherosclerosis

Coarctation
Fibrodysplasia
Arterial tumor
Arterial dissection
Embolism/thrombosis
Vasospasm
Trauma

Takayasus
Temporal arteritis
TOS
Buerger’s

Question 3

Stages of severity

Answer 3

Stage 1: asymptomatic
Stage 2: mild-severe claudication
Stage 3: rest pain
Stage 4: gangrene/ulceration

Question 4

Clinical presentations

Answer 4

presence of risk factors (common)
asymptomatic (common)
intermittent claudication (common)
thigh or buttock pain with walking that is relieved with rest (common)
diminished pulse (common)
sudden onset of severe leg pain accompanied by numbness, weakness, pale, and cold leg (uncommon)
no pulse in lower extremity (uncommon)

Question 5

Risk factors

Answer 5

Smoking
DIabetes
\+Homocysteine
Hyperlipidemia
Age >40
Hx of CAD/CVD
Low levels of exercise

Question 6

History

Answer 6

Presence of risk factors
Aortoilliac->pain in thigh/buttock
Femoropoliteal->pain in calf
PHx: MI, CAD/CVD, renal, RA
Pain on exercise, releived by rest. Worse at night
Erectile dysfunction
Critical-> Leg pain at rest, gangrene, non-healing ulcers, muscle atrophy, dependant rubor, pallor when elevated, loss of hair, thickened toenails, scaly/shiny skin

Pain, parasthesiae, pallor, pulselessness, perishingly cold, paralysis

Question 7

Physical examination

Answer 7

5Ps
Hairless, trophic, scaly, ulcers
Abnormal ABI

CV->Bruits, murmurs, pulses

Question 8

ABI measures

Answer 8

Normal= >0.95
IC= 0.9-0.4
Rest pain= 0.4-0.015
Gangrene=

Question 9

Investigations

Answer 9

ABI
CBC, UEC->may worsen perfusion
ECG->CV risks
Lipids, coags, glucose->CVD risks
ESR/CRP if suspect vasculitis

Other Ix to consider:
segmental pressure
duplex USS
exercise ABI
Angiography->aim to treat
CT/MRA

Question 10

Differential

Answer 10

Spinal stenosis->dermatomal, motor weakness
Arthritis
Venous claudication
Chronic compartment syndrome
Symptomatic baker's cyst

Question 11

Management of chronic limb ischemia

Answer 11

1. Risk factor modification->smoking cessation, diet, exercise, BP, DM->Statin, metoprolol/ACEs, aspirin
2. Supervised exercise therapy->graded walking programmes for 3 months
3. Symptom relief->cilostazol
4. If no relief->consideration for endovascular/surgical management

Question 12

Endovascular revascularisation

Answer 12

Recommended for aortoilliac disease w/ stenosis

Question 13

Surgical revascularisation

Answer 13

aortoiliac disease if stenosis >10 cm, chronic occlusion >5 cm, heavily calcified lesions, or lesions associated with aortic aneurysm.
common femoral artery disease if lesion >10 cm, heavily calcified lesions >5 cm, lesions involving the ostium of superficial femoral artery, and lesions involving the popliteal artery

Question 14

Patterns of claudication depending on arterial involvement

Answer 14

1. Superficial FA->most common.
2. Aortoiliac->Le Riche syndrome= thigh and buttock claudication with erectile dysfunction
3. Combined

Question 15

Management of critical limb ischemia

Answer 15

1. Vascular reconstruction treatment of choice
2. Regular analgesia
3. Protect limb in cage and heel pad
4. Do not elevate limb
5. Alprostadil IV infusion
6. Maintain high/normal BP for perfusion
7. Consider culture and antibiotics->signs of sepsis marked by poor circulation
8. Admit
9. DVT prophylaxis->LMWH

Question 16

Management of acute limb ischemia

Answer 16

1. Brief history->acute onset and numbness, previous episodes, motor. AF, recent MI, IHD, PVD, aortic/mitral valve. Allergies, medication, past history, last meal, events
2. Examination->mottled, dusky, poor pulses, reduced sensation, check motor
3. IV cannulae->send for UEC, FBCs, glucose, clotting
4. ECG->look for AF, MI
5. Oxygen
6. 10mg IV morphine + 10mg metoclopramide
7. Protect limb in cage and heel pad, do not elevate
8. Urgent surgical consult
9. UFH 80u/kg loading dose, then 18u/kg/hour IV infusion
10. May consider thrombolysis->alteplase
11. Admit patient

Question 17

How long in acute limb ischemia before permanent damage

Answer 17

6H