Peripheral Vascular Disease (Ischaemia ILOs)

Question 1

Describe Atherosclerosis

Answer 1

• Affects medium and large arteries
• Caused by chronic inflammation and activation of the immune system in the artery wall
• This cause deposition of lipids in the wall, followed by fibrotic plaques

Question 2

What can atherosclerotic plaques cause?

Answer 2

◦Stenosis leading to reduced blood flow (e.g. in claudication)
◦Rupture giving off a thrombus that blocks a distal vessel leading to ischaemia (e.g. in acute coronary syndrome)

Question 3

Risk factors for atherosclerosis

Answer 3

• Older age
• Family history
• Male
• Smoking and alcohol consumption
• Poor diet (i.e. high trans-fat and reduced fruit and vegetables and omega 3 consumption)
• Low exercise
• Obesity
• Diabetes

Question 4

What resulting pathologies of atherosclerosis are there?

Answer 4

• Angina
• Acute Coronary Syndrome
• Transient Ischaemic Attacks
• Strokes
• Peripheral Arterial Disease
• Chronic Mesenteric Ischaemia

Question 5

Define Peripheral arterial disease

Answer 5

atherosclerosis and narrowing of the arteries supplying the limbs and periphery

Question 6

Define Critical Limb Ischaemia

Answer 6

the end stage of peripheral arterial disease, where there is inadequate supply of blood to a limb to allow it to function normally at rest.

Question 7

What is intermittent claudication?

Answer 7

symptom of having ischaemia in a limb during exertion that is relieved by rest. It is typically a crampy, achy pain in the calf muscles associated with muscle fatigue when walking beyond a certain intensity.

Question 8

What is Leriche’s Syndrome?

Answer 8

•Associated with occlusion in the distal aorta or proximal common iliac artery
•A clinical triad: 
◦Thigh / buttock claudication
◦Absent femoral pulses
◦Male impotence

Question 9

Examination findings in a pt with peripheral vascular disease

Answer 9

•Weak peripheral pulses ◦Radial
◦Brachial
◦Carotid
◦Aorta
◦Femoral
◦Popliteal
◦Dorsalis Pedis
◦Femoral

• Pallor
• Cold
• Skin changes (ulceration, hair loss)
• Buerger’s Test
• You can use a handheld doppler to more accurately assess pulses

Question 10

Investigating peripheral vascular disease

Answer 10

• Ankle-Brachial Pressure Index (ABPI)
• Arterial Doppler
• Angiography (CT or MRI)

Question 11

What is the ankle brachial pulse index?

Answer 11

•The ratio of systolic blood pressure in the ankle (around the lower calf) vs the arm

Question 12

Describe what values are normal and when abnormal, the scale of ischaemic disease

Answer 12

◦>0.9 is normal
◦0.6 – 0.9 is mild disease
◦0.3 – 0.6 is moderate to severe disease
◦<0.3 is severe disease to critical ischaemic

Question 13

What are the 6Ps of critical limb ischaemia?

Answer 13

• Pain
• Pallor
• Pulseless
• Paralysis
• Paraesthesia
• Perishing cold

Question 14

How do you manage intermittent claudication?

Answer 14

• General lifestyle changes to reverse modifiable risk factors (diet, smoking, exercise etc)
• Optimise medical treatment of comorbidities (hypertension, diabetes etc)
• Medical treatments

◦Atorvastatin 80mg
◦Clopidogrel 75mg once daily (alternatively aspirin plus dipyridamole)
◦Naftidrofuryl oxalate (peripheral vasodilator)

•Surgical treatments

◦Angioplasty and stenting
◦Bypass Surgery

Question 15

How is critical limb ischaemia managed?

Answer 15

• Urgent referral to vascular team
• Analgesia
• Urgent revascularisation by

◦Angioplasty and stenting
◦Bypass surgery