Peripheral Vascular Disease (acute and chronic limb ischaemia)

Question 1

Definition

Answer 1

Occurs due to atherosclerosis causing stenosis of arteries via a multifactorial process involving modifiable and non-modifiable risk factors

Question 2

Aetiology

Answer 2

· Occurs due to ATHEROSCLEROSIS in peripheral arteries

· Types of PVD include:

o Intermittent claudication - calf pain on exercise

o Critical limb ischaemia - pain at rest
· NOTE: this is the MOST SEVERE manifestation of peripheral vascular disease

o Acute limb ischaemia - a sudden decrease in arterial perfusion in a limb, due to thrombotic or embolic causes

o Arterial ulcers

o Gangrene

Question 3

Risk factors

Answer 3

Same as for any other atherosclerotic disease

o Smoking
o Diabetes
o Hypertension
o Hyperlipidaemia
o Physical inactivity
o Obesity

Question 4

Epidemiology

Answer 4

· 55-70 yrs = 4-12% affected

· 70+ yrs = 15-20% affected

· More common in MALES

· Incidence increases with AGE

Question 5

Presenting symptoms

Answer 5

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

· Features of Critical Limb Ischaemia
o Ulcers
o Gangrene
o Rest pain
o Night pain (relieved by dangling leg over the edge of the bed)

· Leriche Syndrome (aortoiliac occlusive disease)
o Buttock claudication
o Impotence
o Absent/weak distal pulses

Question 6

Fontaine classification of peripheral vascular disease

Answer 6

o Asymptomatic

o Intermittent Claudication

o Rest pain

o Ulceration/gangrene

Question 7

Signs on physical examination (acute limb ischaemia)

Answer 7

· Acute Limb Ischaemia - 6 Ps

o Pain
o Pale
o Pulseless
o Paralysis
o Paraesthesia
o Perishingly Cold

Question 8

Signs on physical examination (other)

Answer 8

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

Question 9

Investigations (CVS risk assessment)

Answer 9

· Full cardiovascular risk assessment

o Blood pressure
o FBC - anaemia will worsen ischaemia
o Fasting blood glucose
o Lipid levels
o ECG - check for pre-existing coronary artery disease
o Thrombophilia screen - for patients < 50 yrs

Question 10

Investigations (other)

Answer 10

· Colour Duplex Ultrasound
o FIRST-line
o Shows site and degree of stenosis

· MRI/CT
o Assesses extent and location of stenoses

· ABPI (Ankle-Brachial Pressure Index)
o Marker of cardiovascular disease
o ABPI < 0.8 = do NOT apply a pressure bandage because this will worsen ischaemia