Acute and Chronic Limb Ischaemia Flashcards Preview

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Flashcards in Acute and Chronic Limb Ischaemia Deck (33)
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1
Q

What is Peripheral Arterial Disease?

A

Narrowing of the arteries supplying the limbs and periphery, which reduces blood supply to these areas, usually affecting the lower limbs to cause symptoms of claudication.

2
Q

What is Ischaemia?

A

Inadequate Oxygen supply to the tissues due to reduced blood supply.

3
Q

What is Necrosis?

A

Death of tissue.

4
Q

What is Gangrene?

A

Necrosis, specifically due to inadequate oxygen supply.

5
Q

What is Intermittent Claudication?

A

A symptom of limb ischaemia that occurs during exertion and is relieved by rest - typically a crampy, achy pain in the calf, thigh or buttock muscles associated with fatigue when walking beyond a certain intensity.

6
Q

What is Critical Limb Ischaemia?

A

The end stage of Peripheral Arterial Disease where there is inadequate supply of blood to a limb to allow it to function normally at rest.

7
Q

Clinical Presentation of Critical Limb Ischaemia (4).

A
  1. Pain at rest.
  2. Non-healing ulcers.
  3. Gangrene.
  4. Significant risk of losing the limb.
8
Q

What is Acute Limb Ischaemia? (3)

A
  1. Rapid-onset ischaemia in the limb, due to a thrombus blocking the arterial supply (like an MI or stroke).
  2. Surgical Emergency - requires revascularisation within 4-6 hours to save the limb.
  3. Severe symptomatic hypoperfusion of a limb occurring for less than 2 weeks.
9
Q

Causes of Acute Limb Ischaemia (4).

A
  1. 40% - Thrombosis (Rupture of Atherosclerotic Plaques) - sub-acute onset and features of PAD in contralateral limb.
  2. 40% - Embolism (e.g. AF) - acute onset.
  3. Vasospasm e.g. Raynaud’s phenomenon.
  4. External Vascular Compromise e.g. Trauma, Compartment Syndrome.
10
Q

Main Patterns of Presentation of Peripheral Arterial Disease (3).

A
  1. Intermittent Claudication.
  2. Critical Limb Ischaemia.
  3. Acute Limb-Threatening Ischaemia.
11
Q

Why is the pain in Intermittent Claudication worse at night?

A

When the leg is raised, gravity no longer helps pull blood into the foot.

12
Q

What does calf claudication suggest? What does buttock claudication suggest?

A

Calf - Femoral Disease.

Buttock - Iliac Disease.

13
Q

Clinical Presentation of Critical Limb Ischaemia (3).

A

At least 1 of the following 3 :

  1. Pain in the foot at rest for more than 2 weeks.
  2. Ulceration.
  3. Gangrene.
    * Patients report that they hang out their legs out of the bed at night.
14
Q

Clinical Features of Acute Limb Ischaemia (6).

A

6Ps :

  1. Pain.
  2. Pallor.
  3. Pulselessness.
  4. Paralysis.
  5. Paraesthesia.
  6. Poikilothermia (Perishingly Cold).
15
Q

How does gangrene appear?

A

Dark red/Black breakdown of skin.

16
Q

What is Dependent Rubor and how is it a sign of arterial disease?

A

A deep red colour when the limb is lower than the rest of the body.

17
Q

What does the onset of fixed mottling imply?

A

Irreversibility.

18
Q

What is Leriche Syndrome?

  • Clinical Presentation.
  • Aetiology.
  • Management.
A

Clinical Presentation : Triad (MAT) of male impotence, absent femoral pulses, thigh/buttock claudication.
Aetiology : Occlusion in distal aorta/proximal common iliac artery, compromising flow to the pelvic viscera.
Management : if feasible, iliac occlusions are treated with endovascular angioplasty and stent insertion.

19
Q

Investigations of Peripheral Arterial Disease (3).

A
  1. ABPI (Ankle-Brachial Pressure Index) - always,
  2. Angiography (CT/MRI) - before any intervention.
  3. Duplex Ultrasound (Speed and Volume of Blood Flow).
20
Q

What is ABPI?

A

Ratio of systolic BP in the ankle (around lower calf) to systolic BP in the arm. The readings are taken manually using a Doppler probe.

21
Q

Values of ABPI.

A
Normal - 0.9-1.3.
Mild PAD - 0.6-0.9 (Claudication).
Moderate PAD - 0.3-0.6 (Pain at Rest).
Severe PAD / Critical Limb Ischaemia - <0.3.
Calcification (Diabetes) - >1.3.
22
Q

Why is MR/CT Angiography useful?

A

To identify the extent and location of stenosis and quality of distal ‘run-off’ vessels.

23
Q

Management of Intermittent Claudication (4).

A
  1. Lifestyle Changes.
  2. Exercise Training.
  3. Medical Management (Atorvastatin 80mg, Clopidogrel 75mg; Naftidrofuryl Oxalate).
  4. Surgical Management (Endovascular Angioplasty and Stenting; Endarterectomy; Bypass Surgery).
24
Q

What is Exercise Training?

A

A supervised and structured program of regularly walking to the point of near-maximal claudication and pain - rest and repeat, recommended by NICE for all patients with PAD prior to other interventions.

25
Q

How does Exercise Training help?

A

Reduces symptoms by improving collateral blood flow so 2 hours per week for 3 months.

26
Q

What is Naftidrofuryl Oxalate?

A

5-HT2 receptor antagonist that is a peripheral vasodilator.

27
Q

Management of Critical Limb Ischaemia (5).

A

URGENT REFERRAL TO VASCULAR TEAM - revascularise.

  1. Endovascular Angioplasty and Stenting.
  2. Percutaneous Transluminal Angioplasty.
  3. Endarterectomy.
  4. Bypass Surgery.
  5. Amputation of Limb.
28
Q

What does Endovascular Angioplasty and Stenting involve (3)?

A
  1. Insert Catheter into arterial system under X-ray guidance.
  2. Inflate balloon at site of stenosis to create space in the lumen.
  3. Lower risk but not suitable for more extensive disease.
29
Q

When is Percutaneous Transluminal Angioplasty used?

A

Disease limited to a single arterial segment (balloon is inflated in the narrowed segment).

30
Q

Management of Acute Limb Ischaemia (4).

A
  1. A-E.
  2. IV Opioids - Analgesia.
  3. IV Unfractionated Heparin to prevent Thrombus propagation (if not immediate surgery).
  4. Vascular Review.
31
Q

Surgical Management of Acute Limb Ischaemia (3).

A
  1. If thrombotic and ischaemia is complete - bypass surgery.
  2. If thrombotic and ischaemia is incomplete - angiography before endovascular surgery.
  3. If embolic - immediate embolectomy.
32
Q

Indication of Amputation.

A

Patients with critical limb Ischaemia who are not suitable for other interventions e.g. angioplasty or bypass surgery to relieve intractable pain and death from sepsis and Gangrene.

33
Q

Why should the knee be preserved in an amputation?

A

Improves mobility and rehabilitation potential.