Peripheral Vascular disease

Question 1

what are the features of critical limb ischaemia:

Answer 1

pain at rest

MOST SEVERE manifestation of peripheral vascular disease

Can lead to tissue loss – gangrene/ulceration

Gangrene – death of tissue from poor vascular supply, sign of critical ischaemia

Arterial ulcers – abnormal breaks in an epithelial surface

Question 2

what are the risk factors for PVD?

Answer 2

Smoking

Diabetes

Hypertension

Hyperlipidaemia

40yrs+

Physical inactivity

Obesity

Family history

Renal failure

Question 3

what are the types of PVD?

Answer 3

Intermittent claudication

critical limb ischaemia

acute limb ischaemia

Question 4

describe the aetiology of intermittent claudication?

Answer 4

Intermittent claudication - calf pain on exercise

Exercise increases muscle demand, which cannot be met by supply – blood vessels dilates but due to stenosis blood flow doesn’t increase

Improvement occurs by maintaining exercise to stimulate angiogenesis.

Question 5

outline the aetiology of acute limb ischaemia?

Answer 5

a sudden decrease in arterial perfusion in a limb, due to thrombotic or embolic causes, or post angioplasty, trauma, iatrogenic

medical emergency- revascularization within 4-6 hours to save limb as there isn’t time to form its own arteries

Two key causes: atherosclerotic plaque and atrial fibrillation (or malignancy)

In an existing lesion a complication such as thrombosis is more likely than embolus

Question 6

summarise the epidemiology of PVD?

Answer 6

55-70 yrs = 4-12% affected

70+ yrs = 15-20% affected

More common in MALES

Incidence increases with AGE

Question 7

What are the 2 key causes of acute limb ischaemia

Answer 7

atherosclerotic plaque

AF

Question 8

What are the presenting symptoms of intermittent claudication?

Answer 8

cramping pain in the calf, thigh or buttock after walking for a given distance (claudication distance) and relieved by rest

Calf claudication = femoral disease

Buttock claudication = iliac disease

Question 9

what are the presenting symptoms of critical limb ischaemia?

Answer 9

Ulcers

Gangrene

Rest pain

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

Question 10

what are the presenting symptoms of leriche syndrome?

Answer 10

( aortoiliac occlusive disease)

• buttock claudication
• impotence
• absent/ weak distal pulses

Question 11

what are the signs of acute limb ischaemia on physical examination

Answer 11

6 Ps

Pain – constant

Pale

Pulseless – ankle pulses are alwayss absent

Paralysis/ power loss

Paraesthesia

Perishingly Cold/ polar

Question 12

describe Buerger’s test?

Answer 12

Raise patients 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

Patient should then swing legs over bed

A reactive hyperaemia involves the leg first returning to its normal pink colour and 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 13

what classication is used for clinical categorisation accoridng to disease progression of PVD?

Answer 13

Fontaine’s classification

• Stage 1 – Asymptomatic patient
• Stage 2 – Patient suffering from intermittent claudication
• Stage 3 – Ischaemic rest pain
• Stage 4 – Ulceration and/or gangrene

Question 14

What is the gold standard investigation for PVD?

Answer 14

MRI/CT angiogram

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

Question 15

What is the first line investigations for PVD?

Answer 15

ABPI (Ankle-Brachial Pressure Index)

Question 16

If acute limb ischaemia is suspected, how is the investigation different?

Answer 16

give analgesia and heparin and Emergency vascular study assessment should be performed with ankle brachial index or duplex ultrasound

Question 17

what are the investigatioins for PVD?

Answer 17

History and vascular exam

FIRST LINE: ABPI (Ankle-Brachial Pressure Index)

Toe-brachial index (TBI)

Then:Colour Duplex Ultrasound

GOLD STANDARD: MRI/CT angiogram

Full cardiovascular risk assessment

Question 18

interpret the results for ABPI?

Answer 18

Marker of cardiovascular disease

Ankle SBP/Brachial SBP

ABPI < 0.8 = do NOT apply a pressure bandage because this will worsen ischaemia

Note: calcification of arteries can occur in diabetes and renal failure which can alter results and cause high ankle pressures due to incompressible arteries.

Normal: 1-1.2

Peripheral arterial disease: 0.5-0.9 (claudication)

Critical limb ischaemia: <0.5 with tissue loss <0.2- IMMEDIATE SURGICAL CONSULTATION

Question 19

when is toe brachial index useful?

Answer 19

When PAD in patients whom lower extremity is clinically suspected but when ABI is not reliable due to non-compressible vessels e.g. in patients with long-standing diabetes, advanced age, or renal patients– this is when TBI<0.6

Question 20

why is colour duplex ultrasound useful?

Answer 20

Non-invasive

Shows site and degree of stenosis

Question 21

what is included in a full cardiovascular risk assessment?

Answer 21

• Blood pressure
• FBC - anaemia will worsen ischaemia
• Fasting blood glucose
• Lipid levels
• ECG - check for pre-existing coronary artery disease
• Thrombophilia screen - for patients < 50 yrs
• U&E – renal disease

Question 22

summarise the defining symptoms.blood flow and management of intermittent claudication?

Answer 22

Question 23

summarise the defining symptoms.blood flow and management of critical limb ischaemia?

Answer 23

Question 24

summarise the defining symptoms.blood flow and management of acute limb ischaemia?

Answer 24