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- Y6 Cardiovascular > Peripheral vascular disease (acute and chronic limb ischaemia) > Flashcards

Peripheral vascular disease (acute and chronic limb ischaemia) Flashcards

1
Q

What are the three patterns of presentation of PAD?

A

Three main patterns of presentation may be seen in patients with peripheral arterial disease:

  • intermittent claudication
  • critical limb ischaemia
  • acute limb-threatening ischaemia
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2
Q

What is the classification for PAD?

A

Fontaine classification:

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

What is the definition of claudication?

A

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

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4
Q

What is the definition of critical limb ischaemia?

A

Compromise of blood flow to an extremity, causing limb pain at rest. Patients can develop ulcers or gangrene.

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5
Q

What is the definition of acute limb ischaemia?

A

A sudden decrease in limb perfusion that threatens limb viability. Associated with the “6 Ps”: pain, paralysis, paraesthesias, pulselessness, pallor, and poikilothermia.

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6
Q

How common is PAD?

A

Increases with age

40-49yrs - 1%

50-59yrs - ~4%

60-69yrs- 5%

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7
Q

What are the most common causes of acute limb ischaemia?

A
  • Thrombosis - 40%
  • Emboli - 38%
  • Graft/angioplasty occlusion - 15%
  • Trauma
  • Arterial tumour
  • Arterial dissection
  • Vasospasm
  • Takayasu’s
  • Temporal arteritis
  • Thoracic outlet obstruction
  • Buerger’s disease
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8
Q

What are the 6 features of acute limb ischaemia?

A

Features - 1 or more of the 6 P’s

  • pale
  • pulseless
  • painful
  • paralysed
  • paraesthetic
  • ‘perishing with cold’

Pain and numbness occur first because nerves are most sensitive to ischaemia. Lower limb can survive for up tp 6-8 hours before injury becomes irreversible.

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9
Q

What are the feaures of claudication?

A
  • aching or burning in the leg muscles following walking
  • patients can typically walk for a predictable distance before the symptoms start
  • usually relieved within minutes of stopping
  • not present at rest
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10
Q

Name some features of Leriche’s syndrome.

A

Buttock claudication and impotence

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11
Q

What vascular disease are young heavy smokers at risk of?

A

Buerger’s disease - thromboangiitis obliterans (non atherosclerotic smoking related inflammation and thrombosis of veins and medium sized arteries causing thrombophlebitis and ischaemia (–>ulcers, gangrene)

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12
Q

What does buttock claudication as opposed to calf claudication suggest?

A

Buttock - iliac disease

Calf - femoral disease

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13
Q

What are the differentials for peripheral arterial disease?

A
  • Spinal claudication (but all pulses are present)
  • Osteoarthritis of the hip/knee (knee pain often at rest)
  • Peripheral neuropathy (associated with numbness and tingling)
  • Popliteal artery entrapment (young with normal pulses)
  • Venous claudication (bursting pain on walking with previous DVT)
  • Fibromuscular dysplasia
  • Buerger’s disease (young males, heavy smokers)
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14
Q

What tests should you do if you suspect PAD?

A
  1. ABPI & exercise treadmill testing - see if ABPI falls by >0.2 after the exercise (i.e.worse). Exercise component improves the sensitivity of the test.
  2. Duplex ultrasound + doppler - decreased pulsatility between proximal and distal sites, peak systolic velocity >2.0
  3. Catheter angiogram/CTA/MRA - anatomical detail of stenosis or occlusions
  4. Bloods - FBC (plt), PT/PTT, creatinine, lipids, thrombophilia screen, homocysteine levels
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15
Q

What is the ABPI in critical limb ischaemia?

A

An ankle-brachial pressure index (ABPI) of < 0.5 is suggestive of critical limb ischaemia.

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16
Q

How do you interpret ABPI?

A
  • Normal = 1.0-1.2
  • PAD = 0.5-0.9
  • Critical limb ischaemia = <0.5 or ankle systolic pressure <50mmHg
17
Q

What are the 3 L’s to consider when assessing severity of PAD?

A

Life - does it threaten life or will the intervention do so?

Limb - will the patient lose the limb?

Lifestyle - is the lifestyle of pt severely handicapped? Does it require intervention?

18
Q

What is the management of claudication?

A
  • Risk factor modification - quit smoking, treat HTN, statin + antiplatelet for all (aspirin or clopidogrel)
  • Supervised exercise programme - 3 times a week for 45mins for 3 months; improves collateral blood flow. Encourage patients to exercise to the point of maximal pain.
  • Symptom relief -e.g. naftidrofuryl (or cilostazol) but only when patient does not want revascularisation and when exercise offers little benefit.
19
Q

Name 2 drugs which can be used to treat PAD.

A

Naftidrofuryl - vasodilator that inhibits vascular and platelet 5-hydroxytryptamine2 (5-HT2) receptors to reduce lactic acid levels. At dose of 1-200mg TDS it may increase walking distance and improve QoL.

Cilostazol - phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not as effective as the above.

20
Q

What is the management of critical limb ischaemia?

A

Urgent referral to vascular surgeon for revascularisation - risk stratification is done according to the WiFi score

Surgery

If not suitable for surgical revascularisation:

  • Amputation
  • Spinal cord stimulation
21
Q

How do you manage acute limb ischaemia?

A

Urgent referral to vascular surgeons for assessment

Ankle brachial index or duplex ultrasound

Anticoagulation

Paracetamol +/- opioid

Non-viable limb: amputation

Viable limb: revascularisation by:

  • percutaneous catheter-directed thrombolytic therapy
  • percutaneous mechanical thrombus extraction (Fogarty catheter)
  • surgical thrombectomy
  • bypass +/- arterial repair
22
Q

What are the surgical options for PAD?

A

Percutaneous endovascular revascularization - angioplasty +/- stent or balloon placement, used only for short segment stenosis (<10cm), aortic iliac disease

Surgical revascularization- bypass graft in extensive disease. Can be femoral-popliteal, femoral-femoral crossover, and aorto-bifemoral bypass grafts. Autologous vein > prosthetic (Dacron or PTFE) when knee joint is crossed.

Amputation - <3% with claudication require this within 5 years. Can relieve pain and death from sepsis/gangrene.

23
Q

Why should the knee be preserved in amputation? What drug is used to prevent phantom limb syndrome?

A

Improves mobility and rehabilitation potential (must be balanced with the need to ensure wound healing)

Rehabilitation should be started early with a view to limb fitting

Gabapentin is used to treat gruelling complication of phantom limb.

24
Q

What are the complications of PAD?

A

Leg/foot ulcers

Gangrene

Permanent limb weakness/numbness

Permanent limb pain - occurs in non-viable limb

25
Q

What is the prognosis in PAD?

A

ABI is a marker for cardiovascular events beyond the diagnosis of PAD

Claudication - remains stable and does not worsen quickly

Critical limb ischaemia - at 1yr 1in4 will die and 30% will have amputation

Acute limb ischaemia - depends on completeness of revascularisation

26
Q

Summarise compartment syndrome.

A

After acute limb ischaemia, revascularisation can cause reperfusion injury and release of toxic metabolites into the bloodstream. In muscle compartments, consequent oedema may lead to compartment syndrome.

This requires fasciotomies - release of fascia to prevent muscle damage.

27
Q

Name a cause of acute upper limb ischaemia.

A

Usually emboli secondary to compression with a cervical rib/band

28
Q

Where is it more common for an embolus to lodge in the upper limb?

A

50% lodge in BRACHIAL artery

30% in AXILLARY artery

Sources: left atrium with cardiac arrhythmia (which may also present with impaired consciousness), mural thrombus

29
Q

What is the pattern of colour change in Raynaud’s? How is it treated?

A

White –> blue –> red

Calcium antagonists - e.g. nifedipine

30
Q

Lecture:

What are the three main diagnostic features of critical limb ischaemia?

A
  1. Rest pain or tissue loss
  2. >2 weeks duration (otherwise acute ischaemia)
  3. Ankle pressure <40mmHg
31
Q

What is the new name for critical limb ischaemia?

A

Chronic limb threatening ischaemia

- Y6 Cardiovascular (47 decks)

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