Peripheral Vascular Disease (PVD)

Question 1

What causes peripheral vascular disease?

Answer 1

Atherosclerosis builds up in arteries of the limbs (mostly legs) and causes stenosis. This leads to decreased blood supply and oxygen to the muscle causing ischaemia. Ischaemia releases adenosine which causes nerve pain = claudication.

Question 2

Name risk factors of peripheral vascular disease

Answer 2

Smoking
Obesity
Age
Male
Family history of PVD
Diabetes
High lipids
Hypertension

Question 3

What is claudication?

Answer 3

limb pain (including aching, cramping and tired feelings of legs) upon exertion

Question 4

What is claudication distance?

Answer 4

The distance a patient can walk before they experience symptoms

Question 5

Symptoms of peripheral vascular disease in the legs and feet can be divided into 2 categories. What are they?

Answer 5

Mild - intermittent claudication
Severe - critical limb ischaemia (ulceration, gangrene and claudication/foot pain at rest and night - made better by hanging leg over side of bed)

Question 6

peripheral vascular disease in the iliac and femoral arteries cause pain where?

Answer 6

Iliac artery - buttocks pain

Femoral artery - calf pain

Question 7

What are the 5P’s of arterial occlusion?

Answer 7

Pale
Pulseless
Painful
Paralysis
Parasthesia

Question 8

What is Leriche syndrome?

Answer 8

Buttock claudication +/- impotency (erectile dysfunction)

Question 9

What is the name of the classification system for peripheral vascular disease and what are the stages?

Answer 9

Fontaine stages for chronic limb ischaemia
1 - asymptommatic
2 - intermittent claudication
3 - critical ischaemia
4 - necrosis, gangrene, ulceration

Question 10

What Investigations would you do for a patient with peripheral vascular disease?

Answer 10

Bedside - Buergers test, ABPI, BM, ECG
Bloods - FBC (anaemia, polycythaemia), U&Es (renal disease), ESR/CRP (arteritis), lipids
Imaging - 1st line = colour duplex ultrasound scan, MR/CT angio if considering intervention

Question 11

What is Buergers test?

Answer 11

Angle that the leg goes pale when raised off the couch lying down.

Question 12

What Buergers angle and capillary filling time are found in severe ischaemia?

Answer 12

Buergers angle <20 degrees and >15seconds filling time

Question 13

How do you perform and calculate an ABPI?

Answer 13

1. Blood pressure on both arms - take the highest reading
2. BP in both ankles - take highest reading
   All using ultrasound device
3. Divide ankle systolic BP over brachial systolic BP

Question 14

Explain ABPI scores and meanings

Answer 14

0.9-1.2 = normal
0.9-0.5 = peripheral arterial disease
<0.5 = critical ischaemia
>1.3 = calcified vessels give fasely high results

Question 15

Management of peripheral vascular disease?

Answer 15

1. Conservative - stop smoking, loose weight, supervised exercise programmes
2. Control risk factors - diabetes, HTN, antiplatelet agents (clopidogren)
3. symptom management - raise pillow under legs at night can help with pain, foot care
4. Surgery: PTA (percutaneous transluminal angioplasty), surgical reconstruction and bypass graft, amputation.

Question 16

What are the two main causes of acute limb ischaemia?

Answer 16

Thrombus - previously diseased arterial tree
Emboli - previously healthy arterial tree i.e. AF
Other causes:
- trauma
- compartment syndrome
- angioplasty occlusion

Question 17

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

Answer 17

Pale
Painful
Pulseless
Paralysis
Parasthesia
Perishingly cold

Question 18

What is the Management for acute limb ischaemia?

Answer 18

It is an emergency! Must get revascularisation surgery within 4-6hours

1. Call vascular reg
2. bloods - FBC, U&Es, coagulation studies,Group and save
3. other Ix: ECG, CXR
4. Analgesia, commence IV heparin, call radiology for angiography if limb is still viable

Question 19

What complications can arise after initial treatment and revascularisation of an acute limb ischaemia?

Answer 19

Reperfusion injury which can lead to compartment syndrome