Vascular: limb ischemia (acute and chronic) Flashcards
What can PAD lead to?
Intermittent claudication.
What can intermittent claudication lead to?
Acute limb ischaemia or critical limb ischaemia.
Describe presentation of intermittent claudication
Crampy, achy, pain in calf, thigh or buttocks. Muscle fatigue when walking. Occurs at exertion and relieved at rest.
note:intermittent claud is a symptom of PAD
How can claudication be measured?
Claudication distance and Walking distance (maxima walking distance)
What is the claudication distance?
How long pt can walk until the pain starts
What is the walking distance (maximal walking)?
Once the pain has begun, this is how long the pt can continue to walk for
Define acute limb ischaemia
Rapid onset of ischaemia often due to a thrombus blocking blood supply to a limb
QM:
Acute limb ischaemia (ALI) is a severe, symptomatic hypoperfusion of a limb that has been occurring for less than 2 weeks. Although the definition specifies a 2-week period, this condition is considered a surgical emergency and demands urgent intervention, ideally within 4-6 hours.
Define critical limb ischaemia
End stage of PAD - not enough blood supply to limb to allow a normal function at rest. Pt at risk of losing limb
How can pt present with critical limb ischaemia?
- Pain at rest,
- non-healing ulcers,
- gangrene.
- Pain worse at night when leg raised.
- Pt hangs leg off bed to help.
- Burning pain.
What are the 6Ps of critical limb ischaemia?
Pain, pallor, pulselessness, paralysis, parasthesia, perishingly cold.
Causes of acute limb ischaemia?
- thrombosis as a result of ruptured atherosclerotic plaque
- embolism - more common in pts with AF
Other less common causes:
* vasospasm
* external vascular compromise - e.g. trauma and compartment syndrome
Signs and symptoms of acute limb ischaemia?
pulseless
pale
perishingly cold
painful
paralysis
parasthesia
What are differentials for acute limb ischaemia?
- Peripheral vascualr disease - claudication, atrophy of skin and muscles, clow wound healing
- Compartment syndrome - severe pain, pallor, parasthesia, pulseless, paralysis
- DVT - unilateral leg swelling, pain and redness
- Raynaud’s phenomenon - episodic symptoms including pallor, cyanosis, rubor in response to stress or cold.
What initial investigations would you do for ?acute limb ischaemia?
- FBC
- U+E
- Blood group and save
- clotting profile
- ECG - can find potential AF which could have caused emboli.
How is acute limb ischaemia managed?
- refer immediatley to vascular team for management
- if thrombotic cause = angiography to help find occlusion site. Then thrombectomy, angioplasty or intra-arterial thrombolysis if partial ischemai. Urgent bypass surgery if complete ischaemia.
- if embolic cause = immediate embolectomy
definition of peripheral arterial disease?
arises when there’s substantial narrowing of the arteries distal to the aortic arch, typically attributed to atherosclerosis
RF for PAD?
- htn
- hyperlipidaemia
- smoking
- dm
- obesity
- reduced physical activity
signs of PAD?
- pale, cold leg
- hair loss
- ulcers present
- pooly healing wounds
- absent or weak peripheral pulses
differentials for PAD?
- Lumbar spinal stenosis: presents with neurogenic claudication, numbness, tingling, or weakness in the legs, and lower back pain.
- Deep vein thrombosis: swelling, pain, warmth, and redness are commonly observed in the affected leg.
- Diabetic neuropathy: presents with burning or shooting pain, increased sensitivity to touch, and numbness or reduced ability to feel pain or temperature changes.
what inv would you do for possible PAD?
CVS exam
FBC
U+E
Lipid profile
Blood glucose
ECG
Doppler ABPI
For the following ABPI readings - what do they mean?
- 1.2
- 0.9 - 1.2
- 0.8 - 0.9
- 0.5 - 0.8
- < 0.5
- 1.2 = abnormal thickening of vascular walls (usually in DM)
- 0.9 - 1.2 = normal
- 0.8 - 0.9 = mild disease
- 0.5 - 0.8 = moderate
- < 0.5 = severe
how is PAD managed?
Conservative:
* stop smoking
* optimise weight
* increase exercise
Medical:
* clopidogrel 75mg OD
* atorvastatin 80mg ON
* optimise glycaemic and HTN control
* pain management - Naftidrofuryl oxalate, a vasodilator, can alleviate pain in PAD
Surgical:
* endovascular revascularisation
* surgical bypass
* amputation