Peripheral Vascular Disease

Question 1

How many 65-75 year olds have PVD on examination?

Answer 1

1 in 5.

Question 2

How many 65-75 year olds with PVD on examination have symptoms?

Answer 2

1/4.

Question 3

What is an atheroma?

Answer 3

Accumulation of intracellular and extracellular lipid in the intima and media of large and medium sized arteries.

Question 4

What is atherosclerosis?

Answer 4

Thickening and hardening of arterial walls as a consequence of atheroma.

Question 5

What are fatty streaks in atheromas?

Answer 5

Lipid deposits in intima, yellow and raised.

Question 6

What are the features of a simple plaque atheroma?

Answer 6

Raised yellow/white, irregular outline, widely distributed, enlarge and coalesce.

Question 7

What are the features of a complicated plaque atheroma?

Answer 7

Thrombosis, haemorrhage into plaque, calcification, aneurysm formation.

Question 8

Where are the common sites of atheromas?

Answer 8

Aorta, coronary arteries, carotid arteries, cerebral arteries, leg arteries.

Question 9

What are the early microscopic changes of atheromas?

Answer 9

Proliferation of SMC, accumulation of foam cells, extracellular lipid.

Question 10

What are the late microscopic changes of atheromas?

Answer 10

Fibrosis, necrosis, cholesterol clefts, ± inflammatory cells, disrupted internal elastic lamina, media damaged, blood vessel ingrowth, plaque fissuring.

Question 11

What is intermittent claudication?

Answer 11

Pain in the muscles of the lower limb elicited by walking/exercise.

Question 12

Which muscles are mostly affected by intermittent claudication?

Answer 12

Calf muscles - gastrocnemius, soleus, triceps surae.

Question 13

What is the timing of pain of intermittent claudication?

Answer 13

Pain on walking but rapidly relieved by stopping for a few minutes.

Question 14

What causes pain in intermittent claudication?

Answer 14

Muscle oxygen demand and supply -> muscle ischaemia -> anaerobic metabolism -> lactate/K+, substance P -> pain.

Question 15

What are the differential diagnoses for intermittent claudication?

Answer 15

Spinal stenosis, lower limb arthritis, musculoligamentous strain.

Question 16

What are the three most common sites of atheromas causing intermittent claudication?

Answer 16

Superficial femoral artery (80%), aorto-iliac arteries (15%), calf arteries (5%).

Question 17

What are the normal symptomatic presentations of intermittent claudication?

Answer 17

Calf claudication (80%).
Calf, thigh and buttock claudication (18%).
Bilateral buttock claudication + erectile failure = Leriche's syndrome (2%).

Question 18

What are the risk factors for PVD?

Answer 18

Smoking, hypercholesterolaemia/hyperlipidaemia, hypertension, diabetes mellitus, family history, ischaemic heart disease, cerebrovascular disease.

Question 19

What is the natural history of intermittent claudication?

Answer 19

80% will have no progression over 5 year.
After 5 year - 11% who continue to smoke will have an amputation, 0% in those who stop smoking.
Amputation rate over 5 years in diabetics is 4 x normal.

Question 20

Which questions need to be asked in a history of intermittent claudication?

Answer 20

When do they have cramp? When did it start? Is it relieved by rest? How far before pain? Interference with lift? Risk factors? Past medical history?

Question 21

What would be seen on examination of the leg in intermittent claudication?

Answer 21

Inspection - pale colour, poor skin condition, loss of hair.
Palpation - cold temperature, slow capillary refill, weak peripheral pulses, aneurysms.
Auscultation - bruits, heart and carotid auscultation.

Question 22

What are the investigations to be done for intermittent claudication?

Answer 22

FBC, blood glucose, serum lipids. ABPI, treadmill testing.

Question 23

What is ABPI?

Answer 23

Ankle brachial pressure index = ankle systolic pressure/brachial systolic pressure.

Question 24

What is the treatment of intermittent claudication?

Answer 24

Stop smoking, correct risk factors, exercise, percutaneous transluminal angiopalsty, surgical bypass, pharmacological.

Question 25

Why is smoking cessation so important for management of intermittent claudication?

Answer 25

Biggest PAD risk factor, atherogenic, lowers HDL, raises lipids, raises platelet adhesion, raises fibrinogen levels. Stopping increases walking distance, decreases mortality.

Question 26

Which antiplatelet drug should be given in intermittent claudication and why?

Answer 26

Clopidogrel - reduces 5 year risk of combined death/MI/CVA by 25%.

Question 27

Why should statins be given in intermittent claudication?

Answer 27

Reduces 3 year risk of cardiac/CVA events by 25% and mortality by 12%.

Question 28

Which patients with intermittent claudication should be given statins?

Answer 28

All of them - regardless of their starting cholesterol value.

Question 29

What is the purpose of exercise rehabilitation in intermittent claudication?

Answer 29

Improves walking technique, optimises collateral blood distribution, improves capillary perfusion.

Question 30

What is the overall management plan for intermittent claudication?

Answer 30

Assess RF and modify them - stop smoking, exercise. Quality of life affected? Discuss risk/benefit ratios -> angioplasty 20%, surgery 2%, conservative 78% management.

Question 31

What is critical leg ischaemia?

Answer 31

Advanced stage of peripheral artery disease - ischaemia rest pain + arterial insufficiency ulcers + gangrene.

Question 32

What is the history of someone with critical leg ischaemia and rest pain?

Answer 32

Pain at night, relieved by dangling the foot out the bed.

Question 33

What are the signs on examination of critical leg ischaemia?

Answer 33

Pulse status, absence of hair (not massively helpful), cold, paradoxically red (sunset), Buergers test.

Question 34

What is Buergers test?

Answer 34

The angle to which the leg has to be raised before it becomes pale whilst lying down - should be 90 degrees.

Question 35

What are the results of Buergers test in critical limb ischaemia?

Answer 35

15-30 degrees -> pallor, sunset foot where the foot goes red before normal pink due to hyperaemia (anaerobic respiration).

Question 36

What is the management of critical limb ischaemia?

Answer 36

Active, medical management optimisation, angioplasty or bypass surgery to salvage leg, amputation if lots of pain and revascularisation isn’t possible.