Vascular disease

Question 1

What is the Rutherford criteria?

Answer 1

Question 2

What is the immediate treatment for ALI?

Answer 2

Acute limb ischaemia is a surgical emergency. Complete arterial occlusion will lead to irreversible tissue damage within 6 hours. Early senior surgical support is vital.

Start the patient on high-flow oxygen and ensure adequate intravenous access. A therapeutic dose heparin or intravenous heparin infusion should be initiated as soon as is practical.

Question 3

What is the long term management of ALI?

Answer 3

Rutherford 1 and 2a could be conservative.
Rutherford 2b and 3 require targeted surgical therapies
BET and BAT
Bypass, embolectomy and thrombolysis
Bypass, angioplasty and thrombolysis
Treat within 4-6 hours

Question 4

What causes ALI?

Answer 4

Embolism 40% (AF)
Thrombus 40%
Trauma (compartment)

Question 5

What is ALI?

Answer 5

Acute limb ischaemia is defined as the sudden decrease in limb perfusion that threatens the viability of the limb. Refers to this happening in under 2 weeks.

Question 6

What are the 6 Ps?

Answer 6

Pain
Pallor
Pulselessness
Paresthesia
Perishingly cold
Paralysis

Question 7

Describe the investigations for ALI?

Answer 7

Routine bloods, including a serum lactate (to assess the level of ischaemia), a thrombophilia screen (if <50yrs without known risk factors), and a group and save, should be taken, along with an electrocardiogram (ECG).

Suspected cases should be initially investigated with beside Doppler ultrasound scan (both limbs), followed by potential CT angiography

Question 8

What is thromboangitis obliterans?

Answer 8

Buerger’s disease is a non-atherosclerotic small and medium arterial vessel disease linked to smoking and genetic factors. Use arterial doppler, duplex and CT/MRI angiography to show Mortarell’s sign and corkscrew vessels. Patients present with ulcers, thrombophlebitis, Raynaud’s and pain in hands and fingers. To treat SPIN:
Smoking cessation
PGE1
Iloprost
Nifedipine

Question 9

What is shown here?

Answer 9

Mortarell’s sign / corkscrew sign

Question 10

What is the difference between ischaemic ulcers and stasis ulcers?

Answer 10

Ischaemic ulcers are punched out, deep and found more distally. They do not bleed or ooze. In contrast stasis ulcers are to do with a lack of venous return and are found in the Gaiter region or medial malleoli and are wider and shallower. These do ooze and bleed.

Question 11

What is superficial thrombophlebitis?

Answer 11

Question 12

What is the difference between acute and chronic limb ischaemia?

Answer 12

2 weeks

Question 13

What should be prescribed in all patients with peripheral arterial disease?

Answer 13

All patients with peripheral arterial disease should take clopidogrel and atorvastatin

Question 14

What is the difference between PAD and CLI?

Answer 14

Critical limb ischemia (CLI) is a severe blockage in the arteries of the lower extremities, which markedly reduces blood-flow. It is a serious form of peripheral arterial disease, or PAD, but less common than claudication.

Question 15

What is the initial management of ALI?

Answer 15

The initial management of acute limb ischaemia includes analgesia, IV heparin and vascular review

Question 16

When is angioplasty preferred over by-pass?

Answer 16

NICE recommends this type of surgery in preference to bypass surgery for patients with short segment stenosis (<10cm) as it is less invasive.

Question 17

What investigation is first line for ALI?

Answer 17

A handheld arterial Doppler examination should be performed in patients with suspected acute limb ischaemia

Question 18

What crossmatch is done in AAA rupture?

Answer 18

Crossmatch should be arranged in patients with suspected ruptured abdominal aorta aneurysm, most commonly 6 units are ordered