Peripheral Vascular Disease

Question 1

What is peripheral arterial disease?

Answer 1

significant narrowing of arteries distal to the arch of the aorta, most often due to atherosclerosis.

Question 2

What is the fontaine classification for PAD?

Answer 2

1) Asymptomatic
2) Intermittent claudification
3) Ischaemic rest pain
4) Ulceration/ gangrene (critical ischaemia).

Question 3

Other divisions?

Answer 3

Aymptomatic:
Absence of leg claudication symptoms.

Claudication:
Inadequate blood flow during exercise, causing fatigue, discomfort or pain.

Critical limb ischaemia:
Compromise of blood flow to extremity, causing limb pain at rest. Patients often have ulcers or gangrene.

Acute limb ischaemia:
A sudden decrease in limb perfusion that threatens limb viability. 6 Ps = pain, paralysis, paraesthesias, pulselessness, pallor, and perishingly cold.

Question 4

Risk factors

Answer 4

Smoking
diabetes
hyperlipidaemia
physical inactivity
obesity
family history

Question 5

Other signs?

Answer 5

leg numbness
bruits
hair loss
smooth shiny
Buerger's test: <20 degrees
Long cap refill.
absent pulses.
erectile dysfunction.

Physical examination - assessment of all pulses.

Question 6

investigations

Answer 6

1) ABPI: this is the ratio of the blood pressure at the ankle to the blood pressure in the upper arm.
2) doppler scanning
3) ECG
4) Bloods - (esr/crp), glucose, lipids

Question 7

How do you calculate APBI?

Answer 7

• Measure blood pressure on both right and left brachial artery.
• The HIGHER of the two systolic reading will be used as part of the ratio.
• Measure left ankle: over the posterior tibialis, and then dorsalis pedis. (Use the highest of the two for the ratio for the left ABPI)
• Repeat the same process on the right ankle to work out the ratio for the right ABPI.

Question 8

Criteria for ABPI

Answer 8

0.90 to 1.09 is normal
<0.90 is abnormal and indicates presence of PAD
0.41 to 0.90 indicates mild to moderate PAD
<0.40 is severe
>1.40 indicates abnormal, calcified arteries.

Question 9

Treatment

Answer 9

Risk factor modification:

• Quit smoking
• treat hypertension
• high cholesterol, diabetes treat.

ACUTE LIMB ISCHAEMIA:

1) urgent assessment for revascularisation or amputation.
2) Antiplatelet therapyL aspirin or clopidogrel
3) Analgesia
4) Anticoagulation (Heparin).

CLAUDICATION (not lifestyle-limiting)

1) Antiplatelet therapy
2) Exercise: programme for 3 months.
3) Risk factor modication.

CLAUDICATION (Lifestyle-limiting)

1) Antiplatelet therpay
2) Symptom relief = cilostazol, naftidrofuryl, pentoxifylline
3) Revascularisation - may include either percutaneous transluminal balloon angioplasty (PTA) or bypass surgery.