Peripheral Vascular/arterial Disease

Question 1

Definition of PAD

Answer 1

Narrowing of arteries supplying periphery (especially legs)
Essentially IHD of Lower limb arteries

Question 2

Risk factors of PAD?

Answer 2

Smoking, hypertension, ageing, obesity, CKD, T2DM, male, family history

Question 3

Pathology of PVD?
What are the 3 types?

Answer 3

Intermittent claudication (least severe)
Critical limb ischemia (most severe) - chronic
Acute limb ischemia - complication

Question 4

What is intermittent claudication?

Answer 4

Atherosclerosis , partial lumen occlusion
Symptom of ischemia during exertion
Relieved by rest
Crampy achey pain in calf thigh or bum

Question 5

What is critical limb ischemia?

Answer 5

Most severe
End stage PVD
Occlusion is very big, blood supply inadequate to meet metabolic demand
Pain at rest + risk of gangrene/infection + non healing ulcers

Question 6

What is acute limb ischemia ?

Answer 6

Complication
Total occlusion of vessels, due to embolus/thrombus formation at site of critical limb ischemia lesion
Rapid onset of ischemia

Question 7

What are the 6 signs of acute and chronic limb ischemia?

Answer 7

6Ps
Pain - burning pain -worse at nigh (when raised)
Pallor - pale
Pulseless
Paralysis
Paraesthesia - pins and needles
Perishingly cold

Question 8

The more of the 6Ps you have?

Answer 8

The more limb threatening it is
All 6 = deadly

Question 9

Extra: what syndrome is when there is occlusion in distal aorta or proximal common iliac artery ?
What’s the triad of symptoms?

Answer 9

Leriche syndrome

Triad = thigh/buttock claudication
Absent femoral pulse
Male impotence

Question 10

When BV supplying region occluded:
What damage is done in what time?

Answer 10

1. Irreversible nerve damage (within 6 hrs)
2. Irreversible muscle damage (6-10hrs)
3. Skin changes are last to appear therefore likely gangrenous

Question 11

Symptoms of PVD

Answer 11

Skin changes on leg; cooler, ulceration, pallor, hair loss, gangrene
Muscle wasting
Bruits (sound of blood flowing through narrow portion of artery) - pulsatile regions due to turbulent flow
Buerger’s test
Fontaine classification
Some of the Ps

Question 12

What happens in buergers test?

Answer 12

Elevate leg 45^ for 1 min = pallor

Then leg down = blue initially as ischemic tissue deoxygenates blood then reactive hyperaemia = Rubor due to vasodilation

Question 13

What is Fontaine classification?

Answer 13

Stages 1-4
1. Asymptomatic
2. Intermittent claudication
2a = >200m pain free walking
2b=<200m
3. Chronic limb ischemia (pain at rest)
4. Ischemic ulcers - gangrene

Question 14

Diagnosis of PVD

Answer 14

ABPI
Colour duplex ultrasound
CT angiography if surgery considered

Question 15

What is ABPI?
What do the different values mean?

Answer 15

Ankle brachial pressure index
Ratio of systolic BP in ankle (post/ant tibial) compared to arm (brachial) - using Doppler probe/ultrasound

Normal = 0.9 - 1.3

Intermittent claudication = 0.5-0.9

Critical chronic limb ischemia = <0.5 - when absent / very low = risk of acute limb threatening ischemia

> 1.3 = calcification of the arteries (difficult to compress) found in diabetes

Question 16

What does a colour duplex US show?

Answer 16

Speed + vol of blood flow
Imagine - assess degree of stenosis

Question 17

Treatment for intermittent claudication

Answer 17

RF management
(Smoking cessation, decrease BMI (diet and exercise), BP control, statins, anti platelets, T2DM)

Question 18

Treatment for chronic limb ischemia

Answer 18

Revascularisation surgery (PCI If small, bypass if longer)
Amputation if severe

Question 19

Treatment for acute limb threatening ischemia

Answer 19

Surgical emergency - revascularisation within 4-6 hrs otherwise increased amputation risk

Question 20

Complications of PVD

Answer 20

Amputation, permanent limb weakness, rhabdomydysis (increased Ca and K+ released into blood , AKI and arrhythmias)
Risk of cerebrovascular accidents + CVD