Arterial Disease

Question 1

What are the two main types of arterial limb disease?

Answer 1

intermittent claudication

critical limb ischaemia

Question 2

When does intermittent claudication occur?

Answer 2

on exertion / exercise

Question 3

When does critical limb ischaemia occur?

Answer 3

on rest

Question 4

What symptoms do people with intermittent claudication have?

Answer 4

cramp like muscle pain in the calf, thigh and buttocks

Question 5

What age range of people tend to have intermittent claudication?

Answer 5

> 55 years

Question 6

What skin and limb problems can result from critical limb ischaemia ?

Answer 6

ulceration

gangrene

Question 7

What changes to arteries does diabetes cause?

Answer 7

calcification of the arteries which make them less compliant and therefore the lumen size is smaller

Question 8

What two causes can cause intermittent claudication?

Answer 8

atheromatous plaque

diabetes mellitus

Question 9

Name three uncommon causes for intermittent claudication

Answer 9

• beurgers disease
• vasculitis
• hyperhomocysteinaemia

Question 10

Name three main investigations that should be done for intermittent claudication

Answer 10

• Duplex
• Magnetic resonance angiogram
• Ankle Brachial Pressure Index (ABPI) - ankle/brachial pressure (if below 0.4 then prognosis isn’t good)

Question 11

What does PAD mean in terms of intermittent claudication?

Answer 11

peripheral arterial disease

Question 12

Are patients with PAD at high risk of developing coronary heart disease?

Answer 12

yes

Question 13

What two medications should patients with PAD be prescribed?

Answer 13

anti platelets - aspirin or clopidogrel

statins

Question 14

What are anti platelets used for?

Answer 14

to thin the blood and prevent thrombus from forming

decreasing the risk of vessel occlusion

Question 15

What are statins used for?

Answer 15

to reduce the LDLs in the blood and hence reducing the risk of atheromatous plaques from forming
also stabilises the plaque

Question 16

What three other managements should be done for PAD patients other than medication?

Answer 16

• smoking cessation
• screen for diabetes/ manage diabetes properly
• have good control of BP (high BP can result in an embolism)

Question 17

In what two conditions should the ABPI be measured at?

Answer 17

• during rest

- during stress

Question 18

For PAD patients, a procedure called PTA is available for some patients. What does this procedure involve?

Answer 18

involves using a catheter to increase the diameter of the lumen by inserting a balloon and may include inserting a stent into the vessel to ensure the vessel remains open.

Question 19

Can exercise therapy be used to improv the symptoms of intermittent claudication patients?

Answer 19

yes

Question 20

How does exercise therapy help intermittent claudication patients?

Answer 20

o improves BP, dyslipidaemia, endothelial function
- if each day they walk slightly further then they can improve their symptoms gradually and increase the distance they are able to walk

Question 21

What are the risk factors for PAD?

Answer 21

• smoking
• hypercholesterolaemia
• hypertension
• lack of exercise
• poor diet
• diabetes

Question 22

When should angioplasty (PTA) be offered to patients with PAD?

Answer 22

If symptoms are bad and cannot be improved through other methods
AND
the occlusion/damage is over a short distance

Question 23

For how long does PTA improve quality of life for?

Answer 23

2 years

Question 24

When should surgery be considered for PAD patients?

Answer 24

• extensive disease which isn’t suitable for PTA
• if PTA/stenting has failed
• poor quality of life
• risk factors are well managed

Question 25

Is surgery frequently performed for PAD patients?

Answer 25

NO

Question 26

What are the two main types of modern management and give examples for each?

Answer 26

- secondary prevention smoking cessation control BP and diabetes anti platelets and statins ``` - symptom improvement exercise therapy smoking cessation Pharmacotherapy PTA surgery ```

Question 27

What four things does statins inhibit ?

Answer 27

- platelet activation and thrombosis - plaque rupturing - endothelium dilation - inflammatory response

Question 28

What is Dyslipidaemia?

Answer 28

abnormal amounts of lipid in the blood

Question 29

What ideal BP should PAD patients have?

Question 30

What % of intermittent claudication patients are suitable for PTA?

Answer 30

~15%

Question 31

For critical limb ischaemia, does raising the foot increase or decrease the pain for the patient?

Answer 31

increase the pain

Question 32

Why does raising the foot increase the pain for the patient?

Answer 32

- there is less blood flow able to get to the tissue in the periphery as gravity is no longer acting to pull the blood down - therefore there is more anaerobic respiration and more acid building up in the cells - increases the pain in the leg and feet

Question 33

For critical limb ischaemia, would appearance would the feet have if they were raised then lowered again?

Answer 33

they would go pale as they were raised as the feet would have less blood flow they would go bright red as they were lowered again as the collaterals would dilate and fill with blood when lowered.

Question 34

State some methods of secondary prevention for critical limb ischaemia

Answer 34

- smoking cessation - control BP - control diabetes - prescribe anti platelets, ACEI and statins

Question 35

What are the two options if limb ischaemia is severe and the limb needs to be revascularised?

Answer 35

- surgery (fem-pop bypass) | - angioplasty (PTA)

Question 36

If limb ishcaemia is very severe what option is there?

Answer 36

- amputation

Question 37

What is the main complication after surgery for PAD?

Answer 37

MI

Question 38

How does angioplasty compare to surgery?

Answer 38

PTA - less mortality - faster recovery time - lower reobstruction rate - less durable than surgery

Question 39

Where are the four sites where patients are amputated?

Answer 39

digital transmetatarsal below knee above knee

Question 40

What is the difference between acute and chronic limb ischaemia?

Answer 40

acute limb ischaemia has occurred suddenly so there are no collaterals able to carry the blood flow around the occlusion

Question 41

What is the presentation of acute limb ischaemia ? | 6 signs

Answer 41

``` pain pulseless paraethesia (pins and needles) pallor paralysis perishingly cold ```

Question 42

What are the two causes of acute limb ischaemia and what are the % of cases?

Answer 42

- embolism (30%) | - in situ thrombosis (60%)

Question 43

Name four other uncommon causes of acute limb ischaemia

Answer 43

- trauma (leg fracture, dislocation, stab wounds, iatrogenic) - popliteal aneurysm - thoracic dissection - intra arterial drug administration

Question 44

What examination would you do to determine the severity of the acute limb ischaemia? 4 things

Answer 44

- peripheral pulses present? including above femoral - is sensation or movement restricted or absent in the limb - is atrial fibrillation present? (heart related?) - how long has it lasted?

Question 45

What are the treatment options for acute limb ischaemia that has been caused by an embolus if the leg is salvageable ?

Answer 45

- if urgent then embolectomy should be performed to remove the embolus - if there is time available then thrombolysis should be administered pain relieve and heparin should also be given ensure the area of ischaemia has been reperfused

Question 46

What are the treatment options for acute limb ischaemia that has been caused by a thrombosis if the leg is salvageable ?

Answer 46

Angiography should be performed to determine the severity of the occlusion ``` Severity will determine whether - thrombolysis - PTA - by pass is required ```

Question 47

What are the contradictions for thrombolysis ?

Answer 47

- recent haemorrhage - recent bleed - recent surgery - GI bleed - recent stroke - over 80 years

Question 48

If acute limb ischaemia has been caused by an embolism, how long does the patient have been the leg is unsalvageable?

Answer 48

6-8 hours