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MET3a > Chronic Limb Ischaemia > Flashcards

Chronic Limb Ischaemia Flashcards

1
Q

Signs and symptoms

A 
Ulceration
Gangrene
Calf pain at rest
<50mmHg at ankle
Absent femoral/popliteal/foot pulses
Atrophic skin
Punched out ulcers
Cold/pale legs
Bueger's Angle <20 degrees
Capillary Refill>15 secs
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2
Q

What is Bueger’s Angle?

A

Angle that leg goes pale when raised off couch

Test for reactive hyperaemia if <20

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3
Q

Phases of disease

A

Asymptomatic
Intermittent Claudication
Critical Limb Ischaemia
Gangrene/Ulcers

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4
Q

Define intermittent claudication

A

Pain on exertion only
Relieved by rest
Typically in calves
Due to muscle not getting enough oxygen

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5
Q

Define critical limb ischaemia

A 
Extreme of intermittent claudication
Pain at rest >2 weeks
Presence of ischaemic lesions/gangrene
ABPI
Ankle pressure <50mmHg
Lose sensation then movement then pain
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6
Q

Differentials for calf pain

A 
Leriche's syndrome
Buerger's disease
Spinal stenosis
Venous claudication
Chronic compartment syndrome
Baker's cyst
Acute limb ischaemia
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7
Q

Define Leriche’s syndrome

A

Buttock claudication with or without impotence

With leg pain

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8
Q

Who gets Buerger’s disease?

A

Young heavy smokers

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9
Q

How to distinguish with spinal stenosis?

A

Lower back pain radiating down lateral leg

Relieved by sitting/lying down for longer time

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10
Q

How to distinguish with venous claudication?

A

Venous congestion & oedema
Worse in thigh/groin
Relieved by elevation

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11
Q

How to distinguish with chronic compartment syndrome?

A

Tight burst calf pain after exercise in athletes

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12
Q

How to distinguish with Baker’s cyst?

A

Pain in calf and behind knee at rest

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13
Q

How to distinguish with acute limb ischaemia

A

Symptoms for <14 days

Sudden onset

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14
Q

RF of chronic limb ischaemia

A

Smoking
DM
Dyslipidaemia
HTN

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15
Q

Ix for chronic limb ischaemia

A

Buerger’s Test
ABPI
Duplex Doppler USS
MRI/CT

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16
Q

ABPI

A

Ratio of systolic BP in lower leg to that in arms

ABPI<1 = lower BP in legs = peripheral arterial disease

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17
Q

Use of ABPI

A

To diagnose peripheral arterial disease
In patients with leg ulcers
Can be harmful = further restricts blood supply to foot

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18
Q

Interpretation of ABPI

A 
>1.2 = calcified, stiff arteries, age, PAD
1-1.2 = normal
0.9-1 = acceptable
<0.9 = likely PAD
0.6-0.9 = claudication
0.3-0.6 = rest pain
<0.3 impeding
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19
Q

Mild, moderate and severe PAD

A

Mild ABPI = 0.8-0.9
Moderate ABPI = 0.5-0.9
Severe = <0.5 = urgent referral

20
Q

Duplex Doppler USS

A

Location and degree of stenosis

Stenosis >50% systolic velocity ratio

21
Q

When to do a MRI/CT?

A

When considering intervention

22
Q

Treatment Methods

A

Percutaneous Transluminal Angioplasty
Arterial Reconstruction Surgery - bypass
Limb Amputation

23
Q

What is percutaneous transluminal angioplasty?

A

Catheter inserted into artery in groin/arm
Balloon inflated for a minute each time
Pushes fatty deposits
Preferred when patient has severe co-morbidities

24
Q

Indications for percutaneous transluminal angioplasty?

A

Disease limited to single artery

25
Q

Complications for PTA?

A 
MI
Arrhythmias
Haemorrhage
Wound infection
Peripheral Oedema
Thrombosis
PE
Bleeding at Catheter insertion sits
Blood clot/damage to vessel
Restenosis of vessel
Nerve injury
26
Q

What is arterial reconstruction surgery?

A

Vessel graft to divert blood flow from affected vessel
Stitch on graft at place above and below damaged vessel
Preserved for patients with critical limb ischaemia
Use patient’s own vein (autologous) - may have to reverse if valves or destroy valves
Synthetic = PTFE (gortex)/Dacron = must use vein cuff to control turbulent flow at entry to vessel

27
Q

Aorto-iliac disease

A

Stenosis >10cm
Chronic occlusion >5cm
Heavy calcified lesions

28
Q

Common femoral artery disease

A

Lesions >10cm
Heavy calcified lesion>5cm
Lesion involving ostium of superficial femoral artery
Lesion involving popliteal artery

29
Q

Complications of femoral artery disease

A 
Thrombosis
Lower limb compartment syndrome
Abdominal compartment syndrome
Graft infections
Pseudoaneurysms
AV fistulae
Aortoenteric fistulas
30
Q

What is limb amputation?

A

Myodesis = shortening and smoothing out bone in remaining limb

31
Q

Indications for limb amputation

A

Acute limb ischaemia - non viable limb

Chronic critical limb ischaemia - unsuitable for revascularisation

32
Q

Rehabilitation post amputation

A

Day 1-2 = stump with bandage, wheelchair
3-5 = lie flat, straighten hip, exercise
6-10 = exercise 1-2x a day, stump shrinker compression sock, pneumatic post-amputation mobility aid to reduce stump swelling
10-21 = remove stitches, attend amputee rehab unit, offer prosthesis if appropriate

33
Q

Pain control in palliative support

A

NSAIDs - ibuprofen
Anticonvulsants - Carbamazepine/Gabapentin
Antidepressants - amitriptyline
Opoids - codeine/morphine
Corticosteroid/Local anaesthetic injection

34
Q

Common peripheral vascular issues

A 
Arteries
- occlusive disease
- aneurysmal diseases
- arterial dissection
Veins
- chronic venous insufficiency
35
Q

What can happen after a plaque formation?

A
  • aneurysm & rupture
  • occlusion by thrombus
  • critical stenosis
36
Q

Define rest pain

A

Constant pain and need opiates

Normally at night

37
Q

Medical Therapy to control RF

A
  • diabetes control - reduce HbA1C by 1-21%
  • cholesterol = 80mg of atorvostatin for all!
  • BP control
  • antiplatelets = aspiring/clopidogrel 75mg for all tolerant!
  • anti-oxidants and vitamins = omega-3 fish oils
38
Q

Benefits of angioplasty

A

Minimally invasive
Short stay
Quick recovery

39
Q

Why are veins better for bypass?

A

Last longer than prosthetic grafts

Long saphenous better than umbilical

40
Q

Risks of bypass

A 
Graft failure
MI
Infections - esp prosthetics
Limb loss
Death
41
Q

Benefits of bypass

A

Save limb
Retain independence
Wound healing

42
Q

Who is eligible for bypass?

A

If going to be alive for >2 yrs = do bypass
Otherwise angioplasty
Aorto-iliac disease
Common femoral artery disease

43
Q

Allen’s test

A

Occlusion of radial and ulnar arteries when fist is clenched

Colour return in 15 seconds when open hand if adequate arterial circulation = collateral

44
Q

Indications for arterial reconstruction

A

Graft infection
Thrombosis
Lower Limb compartment syndrome

45
Q

Indications for amputation

A

Tissue Loss

Claudication continuation despite bypass graft

46
Q

How to complete a venous examination?

A
  • DRE
  • abdomen exam
  • pelvic exam
47
Q

Define lipodermatosclerosis

A

Inflammation of fat layer under epidermis

MET3a (38 decks)

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