Peripheral Vascular Disease

Question 1

What is PVD?

Answer 1

range of arterial syndromes caused by atherosclerotic obstruction of lower-extremity arteries

Question 2

Describe the aetiology of PVD

Answer 2

ATHEROSCLEROSIS in peripheral arteries

Question 3

What are the 3 types of PVD?

Answer 3

Intermittent claudication: calf pain on exercise
Critical limb ischaemia: pain at rest
Acute limb ischaemia: sudden decrease in arterial perfusion in a limb, due to thrombi/ emboli

Question 4

What is the most severe manifestation of PVD?

Answer 4

Critical limb ischaemia

Question 5

List 6 risk factors for PVD

Answer 5

Smoking  
Diabetes  
HTN  
Hyperlipidaemia  
Physical inactivity  
Obesity

Question 6

Describe pain in intermittent claudication.

Answer 6

cramping pain in the calf, thigh or buttock after walking for a given distance (claudication distance) + relieved by rest
Calf claudication = femoral disease
Buttock claudication = iliac disease

Question 7

Give 4 features of critical limb ischaemia on presentation

Answer 7

Ulcers
Gangrene
Rest pain
Night pain (relieved by dangling leg over edge of the bed)

Question 8

Give 3 features of Leriche Syndrome (aortoiliac occlusive disease) on presentation

Answer 8

Buttock claudication
Impotence
Absent/ weak distal pulses

Question 9

What are the 6P’s of acute limb ischaemia?

Answer 9

Pain (constant)
Pallor 
Pulseless (ankle pulses are always absent)
Paralysis/ power loss  
Paraesthesia 
Perishingly Cold/ polar

Question 10

List 4 signs of peripheral vascular disease

Answer 10

Atrophic skin
Hairless
Punched-out ulcers (often painful)
Colour change when raising leg (to Buerger’s angle)

Question 11

What is BUERGER’S TEST?

Answer 11

Raise pts legs to 45 degrees for a few minutes
If limb develops pallor, note at what angle (20’ = buergers angle)
< 20 = severe limb ischaemia
Limb should remain pink even at 90 degrees
Pt should then swing legs over bed
A reactive hyperaemia involves the leg first returning to its normal pink colour + then becoming red in colour.
This colour change occurs as a result of arteriolar dilatation, which is a response to increased anaerobic metabolic waste build up in the lower limbs.

Question 12

Describe the Fontaine classification of PVD

Answer 12

Stage 1 – Asymptomatic patient
Stage 2 – Intermittent claudication
Stage 3 – Ischaemic rest pain
Stage 4 – Ulceration +/or gangrene

Question 13

Describe first steps taken when a patient presents with acute limb ischaemia

Answer 13

Analgesia + heparin

Emergency vascular study assessment with ABPI or duplex US

Question 14

What is the 1st line investigation in PVD?

Answer 14

ABPI (Ankle-Brachial Pressure Index)
Normal =1-.1.2
ABPI < 0.8 = do NOT apply a pressure bandage because this will worsen ischaemia

Question 15

List 4 investigations performed in PVD

Answer 15

ABPI
Toe-brachial index (TBI)
Colour Duplex US
MRI/CT angiogram

Question 16

What is the gold standard investigation for PVD?

Answer 16

MRI/CT angiogram

Fast, non-operator-dependent ix, but has associated risks of contrast use

Question 17

What further investigations should be performed for PVD?

Answer 17

BP
FBC: anaemia will worsen ischaemia  
Fasting blood glucose  
Lipid levels  
ECG: check for pre-existing coronary artery disease 
Thrombophilia screen: for pts < 50 yrs  
U+E: renal disease

Question 18

Describe the epidemiology of PVD

Answer 18

55-70 yrs = 4-12% affected
70+ yrs = 15-20% affected
M > F
Incidence increases with AGE

Question 19

What combination of features indicate acute on chronic limb ischaemia?

Answer 19

Erythema
Other leg affected
Hx of claudication
6P’s

Question 20

How are the 3 forms of PVD treated?

Answer 20

Intermittent claudication: Conservative + medical
Critical limb ischaemia: Surgical e.g. bypass
Acute limb ischaemia: Surgical e.g. embolectomy