Peripheral Vascular Disease

Question 1

What does the abdominal aorta become at its bifurcation

Answer 1

common iliac arteries

Question 2

What do Common Iliac arteries give rise to

Answer 2

Internal Iliac artery

External Iliac artery (continues as main vessel)

Question 3

At groin crease, what does external iliac artery become

Answer 3

Common femoral artery (branch of profunda femoris artery)

Question 4

What does the Common femoral artery become

Answer 4

Superficial femoral artery

Question 5

What does suprficial femoral artery become at knee crease

Answer 5

Popliteal artery

Question 6

What does popliteal artery bifurcate into

Answer 6

Tibio-peroneal trunk

Anetrior tibial artery

Question 7

What does tibio-peroneal trunk bifurcate into

Answer 7

Peroneal artery

Posterior tibial artery

Question 8

What does peripheral vascular disease refer to?

Answer 8

Partial blockage of leg
or peripheral vessels by an
atherosclerotic plaque and or resulting thrombus resulting in insufficient perfusion of the lower limb resulting in
LOWER LIMB ISCHAEMIA

Question 9

Is peripheral vascular disease more common in men or women

Answer 9

Men

Question 10

What arteries (around lower limb) are generally affected by peripheral vascular disease or atherosclerosis

Answer 10

Aorta-iliac

Infra-inguinal

Question 11

Peripheral vascular disease risk factors

Answer 11

• Smoking
• Diabetes
• Hypercholesterolaemia
• Hypertension
• Physical inactivity
• Obesity

Question 12

Cause of peripheral vascular disease

Answer 12

Atherosclerosis of arteries distal to aortic arch

Question 13

Peripheral vascular disease - oxygen pressure at rest

Answer 13

Normal

Question 14

Peripheral vascular disease - oxygen pressure when begin exercise

Answer 14

Normal

Question 15

Peripheral vascular disease - oxygen pressure when do moderate exercise

Answer 15

Normal

Question 16

Peripheral vascular disease - oxygen pressure when do hard exercise

Answer 16

Low

Question 17

Peripheral vascular disease - oxygen pressure when have short rest or long rest

Answer 17

Short rest - normal

Long rest - normal

Question 18

Features of mild ischaemia

Answer 18

Stress-induced physiological malfunction
Exercise induced angina
Intermittent claudication

Question 19

*What is Intermittent claudication

Answer 19

Cramping pain that is induced by exercise and relieved by rest.
Occurs when anaerobic metabolism comes into effect when oxygen demand outstrips supply

Question 20

Features of intermittent claudication

Answer 20

Pain distal to site of atheroma.
Pain is result of lactic acid production.
Caused by inadequate blood supply to the affected muscles resulting in moderate ischaemia.
Leg pulses are often absent and feet may be cold.

Question 21

In what muscles is intermittent claudication most common seen

Answer 21

Calf and leg muscles as a result of atheroma in the legs.

Question 22

Oxygen pressures in different activities with intermittent claudication:
At rest
Begin exercise
Moderate exercise
Hard exercise
Short rest
Long rest

Answer 22

At rest - normal
Begin exercise - normal
Moderate exercise - low
Hard exercise - low
Short rest - low
Long rest - normal

Question 23

Describe features of critical limb ischaemia

Answer 23

• Blood supply is BARELY ADEQUATE to allow basal
metabolism
• No reserve available for increased demand
• Rest pain that is typically NOCTURNAL
• Risk of gangrene and/or infection
• CHRONIC CONDITION and the MOST SEVERE clinical
manifestation of peripheral vascular disease

Question 24

Oxygen pressures in different activities with critical limb ischaemia:
At rest
Begin exercise
Moderate exercise
Hard exercise
Short rest
Long rest

Answer 24

At rest - low
Begin exercise - low
Moderate exercise - low
Hard exercise - low
Short rest - low
Long rest - low

Question 25

What diseases can result from moderate ischaemia in peripheral vascular disease

Answer 25

Ischaemic cardiac failure Critical limb ischaemia Vascular dementia

Question 26

What diseases can result from severe ischaemia in peripheral vascular disease

Answer 26

Infarction | Gangrene

Question 27

General symptoms of chronic lower limb ischaemia

Answer 27

Absent femoral, popliteal or foot pulses | Cold, white legs

Question 28

Differential diagnosis of chronic lower limb ischemia

Answer 28

Osteoarthritis of hip/knee due to knee pain at rest | Peripheral neuropathy - associated with tingling

Question 29

*Diagnosis of chronic lower limb ischemia

Answer 29

Colour duplex ultrasound (1st line) ESR/CRP (to exclude arteritis - in which results would be raised) FBC - look at Hb levels to exclude anaemia or polycthaemia (increased RBCs) ECG - cardiac ischaemia MRI/CT angiography to assess extent and location of stenoses and quality of distal vessels (if considering intervention)

Question 30

How can you analysis severity of chronic lower limb ischaemia

Answer 30

Ankle/Brachial Pressure Index (ABPI) Measurement of the cuff pressure at which blood flow is detectable by Doppler (ultrasound that measures blood flow) in the posterior tibial or anterior tibial arteries compared to the brachial artery

Question 31

What value range would classify intermittent claudication on and Ankle/Brachial Pressure index

Answer 31

0.5 to 0.9

Question 32

What value range would classify critical leg ischaemia on and Ankle/Brachial Pressure index

Answer 32

<0.5

Question 33

Causes of acute lower limb ischaemia

Answer 33

Embolic disease (commonly due to cardiac arrhythmias and cardiac thrombus or secondary to aneurysm thrombus or thrombus on atherosclerotic plaques) Thrombotic disease (more common - forms in patients who are hypercoagulable due to malignancy or thrombophilia effects)

Question 34

*Symptoms of acute lower limb ischaemia

Answer 34

``` Pain Pallor Perishing cold Pulseless Paralysis Paraesthesia (pins and needles or abnormal tinging/prickling) ``` The more Ps present the more sudden and complete your ischaemia

Question 35

Treatment of peripheral vascular disease

Answer 35

Risk factor modification | Revascularisation for critical ischaemia

Question 36

Risk factor modification for treatment of peripheral vascular disease

Answer 36

Smoking cessation Treat hypertension, hyperlipidemia and diabetes Antiplatelet agent such as P2Y12 inhibitor e.g. Clopidogrel to prevent progression and minimise risk Exercise and weight loss

Question 37

Why is smoking bad for peripheral vascular disease

Answer 37

Every time you smoke, small vessel in the muscles near to ischaemia (that provide 'back up supply') contract in response to nicotine and tobacco resulting in a reduction in blood flow through them (bad)

Question 38

*Describe how revascularisation can be used to treat critical ischaemia

Answer 38

Percutaneous transluminal angioplasty (essentially squash plaque and thus increase perfusion and reduce ischaemia) Bypass procedure Amputation if severe

Question 39

Describe treatment of acute ischaemia

Answer 39

SURGICAL EMERGENCY requiring REVASCULARISATION WITHIN 4-6 HOURS TO SAVE THE LIMB This is an EMERGENCY and requires urgent surgery and angioplasty (widening of arteries with balloon) Intra-arterial thrombolysis Surgical removal of embolus if present

Question 40

What is Intermittent claudication

Answer 40

Ischaemic leg pain Tissue is NOT DYING just SUFFERING In moderate exercise, you have oxygen debt resulting in a build up of lactic acid resulting in pain

Question 41

What is critical ischaemia

Answer 41

Tissue is DYING and SUFFERING AT REST Blood supply is inadequate to allow basal metabolism No reserve available for the increased demand Resting pain - typically NOCTURNAL Gangrene/infection risk

Question 42

Diagnosis of Severe nocturnal pain in all toes of the left foot only relieved by hanging foot over the edge of bed (using gravity to perfuse)

Answer 42

Critical Ischaemia

Question 43

Diagnosis of Loss of the use of right side of body and fast irregular pulse

Answer 43

Acute Ischaemia

Question 44

Diagnosis of Non-healing painful ulcer on big toe with no trauma

Answer 44

Critical Ischaemia