Vascular: limb ischemia (acute and chronic)

Question 2

What can PAD lead to?

Answer 2

Intermittent claudication.

Question 3

What can intermittent claudication lead to?

Answer 3

Acute limb ischaemia or critical limb ischaemia.

Question 4

Describe presentation of intermittent claudication

Answer 4

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

Question 5

How can claudication be measured?

Answer 5

Claudication distance and Walking distance (maxima walking distance)

Question 6

What is the claudication distance?

Answer 6

How long pt can walk until the pain starts

Question 7

What is the walking distance (maximal walking)?

Answer 7

Once the pain has begun, this is how long the pt can continue to walk for

Question 8

Define acute limb ischaemia

Answer 8

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.

Question 9

Define critical limb ischaemia

Answer 9

End stage of PAD - not enough blood supply to limb to allow a normal function at rest. Pt at risk of losing limb

Question 10

How can pt present with critical limb ischaemia?

Answer 10

• Pain at rest,
• non-healing ulcers,
• gangrene.
• Pain worse at night when leg raised.
• Pt hangs leg off bed to help.
• Burning pain.

Question 11

What are the 6Ps of critical limb ischaemia?

Answer 11

Pain, pallor, pulselessness, paralysis, parasthesia, perishingly cold.

Question 12

Causes of acute limb ischaemia?

Answer 12

• 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

Question 13

Signs and symptoms of acute limb ischaemia?

Answer 13

pulseless
pale
perishingly cold
painful
paralysis
parasthesia

Question 14

What are differentials for acute limb ischaemia?

Answer 14

• 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.

Question 15

What initial investigations would you do for ?acute limb ischaemia?

Answer 15

• FBC
• U+E
• Blood group and save
• clotting profile
• ECG - can find potential AF which could have caused emboli.

Question 16

How is acute limb ischaemia managed?

Answer 16

• 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

Question 17

definition of peripheral arterial disease?

Answer 17

arises when there’s substantial narrowing of the arteries distal to the aortic arch, typically attributed to atherosclerosis

Question 18

RF for PAD?

Answer 18

• htn
• hyperlipidaemia
• smoking
• dm
• obesity
• reduced physical activity

Question 19

signs of PAD?

Answer 19

• pale, cold leg
• hair loss
• ulcers present
• pooly healing wounds
• absent or weak peripheral pulses

Question 20

differentials for PAD?

Answer 20

• 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.

Question 21

what inv would you do for possible PAD?

Answer 21

CVS exam
FBC
U+E
Lipid profile
Blood glucose
ECG
Doppler ABPI

Question 22

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

Answer 22

• 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

Question 23

how is PAD managed?

Answer 23

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