Arterial diseases of the limbs

Question 1

What is the clinical presentation of arterial occlusive disease?

Answer 1

Cold, loss of pallor, painful leg.

Question 2

What is the clinical presentation and progression of venous disorders?

Question 3

What are the surgical interventions available for the treatment of arterial occlusive disease?

Answer 3

Stents or bypass

Question 4

What does aorta divide into?

Answer 4

Aorta - illiac - common femoral (-cprofunda femoris) - Superficial femoral artery - popliteal artery - (ant tib - dorsalis pedalis) (Peroneal artery) (Posterior tibial artery)

Question 5

How to feel aortic pulse?

Answer 5

2 hands above umbillicus

Question 6

Check now you can feel common femoral, popliteal and posterior tibial and dorsalis pedilais

Answer 6

hip crease, under knee (relaxed knee), inside of inside ankle, on foot

Question 7

What is Chronic Limb Ischemia?

Answer 7

Long term atherosclerotic disease in leg arteries, causing claudication or some form of ischemia eg on excertion

Question 8

What are the risk factors for CLI?

Answer 8

Male
Age
Smoking
Hypercholesterolemia
Hypertension
Diabetes

Question 9

What are the 4 stages of CLI (Fontaine classification)

Answer 9

Stage I - No symptoms, incomplete blood vessel occlusion
II = IIa Claudication on walking over 200m, IIb claudication on walking under 200m
III = at rest pain in feet
IV = Gangrene/necreosis

Question 10

Which stages are critical limb ischemia?

Answer 10

Stage III and IV (rest pain and gangrene/necrosis)

Question 11

What is claudicaition?

Answer 11

Cramping/gripping sensation in calfves caused by ischemia

Question 12

What factors should you ask about claudcation?

Answer 12

When, how long, exact location, exacerbating/relievling factors, bilateral, exercise tolerance, pain type.

Also think about Risk factors
Past Medical History
Drug History
Occupational History – Daily Habits
Surgical History

Question 13

What are claudication relieving factors?

Answer 13

Dangling feet off bed

Question 14

What foot symptoms are signs of chronic limb ischemia? Do you need to look at both legs?

Answer 14

Yes need to look at both legs to compare. Think UPH- Chonic limb ischemia!

Ulceration
Pallor
Hair loss

Question 15

What is the hand held doppler used for?

Answer 15

To auscultate the dorsalis pedis and posterior tibial pulses

Question 16

What do you need to feel for in clinical exam before the doppler exam?

Answer 16

Temperature
Capillary refill time
Peripheral sensation
Pulses – start at the aorta

Question 17

What is ABPI?

Answer 17

Arterial Brachial Pressure Index:

Ankle Pressure (mmHg) / Brachial Pressure (mmHg)

A good measurement for the amount of occlusion of the arteries.

Question 18

WHat is a healthy ABPI?

Answer 18

greater than 1

Question 19

ABPI critical limb ischemia

Answer 19

Under 0.5

Question 20

intermittent claudication abpi

Answer 20

0.5-0.95

Question 21

Gangrene and ulceration abpi

Answer 21

less than 0.2

Question 22

What is Beurger’s test?

Answer 22

You lift the legs and thne put them back down, if has limb ischemi, then blood flow retunr will be slow and will turn darker colours

Question 23

Why does foot go to dark red colour?

Answer 23

Because it is chronic limb ischemia. usually in healthy leg approx only 1/3 capillaries etc are dilated, but due to hypoxia, all vessels are dilated.

Question 24

What investigations can be used for CLI? Pros and cons

Answer 24

Duplex - no contrast or radiation required, produces dynamic image. Not good on abdomen, operator dependant and time consuming.

MRACTA - clearer, requires ratiation/contrast and can overestimate calcification/difficult in low flow states

Question 25

What is first line invesitgation according to NICE?

Answer 25

CTA/MRA

Question 26

What usually follows a digital subtraction angiography?

Answer 26

Angioplasty (stent)

Question 27

Wgat is angioplasty?

Answer 27

Stent

Question 28

What is best medical therapy for Chronic Limb Ishemia?

Answer 28

combination of antiplatelet and statin Antiplatelet: Reduces risk of requiring revascularization as well as cardiovascular and all-cause mortality Statin: Inhibits platelet activation and thrombosis, endothelial and inflammation activation, plaque rupture by lowering LDL cholesterol in blood.

Question 29

How can we control risk factors in CLI?

Answer 29

Stop smoking, increasing walking 150%, controlling diabetes (10% peeps are unknown diabetes), managing bp (ideally 140/85)

Question 30

What are the 2 options for revasularisation

Answer 30

Endovascular intervention (balloon angioplasty/stent/atherectomy) and open surgery (bypass/endarterectomy)

Question 31

What is required for a surgical bypass?

Answer 31

In and out flows and something to put in the middle (ocnduit) eg synthetic or vein

Question 32

Give examples of General and Technical risks of complications arising from surgical bypass

Answer 32

General : Bleeding, wound infection, pain, scar, DVT, PE, MI, CVA, LRTI, death (2%) Technical :Damage to nearby vein, artery, nerve, distal emboli, graft failure (stenosis, occlusion)

Question 33

Which options are better short/long term?

Answer 33

Short term endothelial (stent) long term is bypass

Question 34

What is acute limb ischemia? And causes?

Answer 34

Medical emergency - usually as a result of throbus or embolism. Severe limb ischemia, limb will die within 6-8h. Pathophysiology:Arterial embolus: MI, AF, proximal atherosclerosis (NOT DVT/PE) Thrombosis: Usually thrombosis of a previously diseased artery. Trauma Dissection Acute aneurysm thrombosis i.e. popliteal

Question 35

What are the 6Ps of acute limb ischemia? What do you have to compare?

Answer 35

``` Pain Pallor Pulse deficit Poikilothermia (cold) Paralysis/Paresis (muscular weakness) Paraethesia (abnormal sensatino eg pins and needles) ```

Question 36

What is compartmet symdrome?

Answer 36

When an area is shut off for more than 6-8 hours, swelling, blocks weins, tender calf, Creatinine kinase increase, increased risk of renal failure. Muscle ischaemia (irreversible after 6-8 hours) Inflammation, oedema, venous obstruction Tense, tender calf Rise in creatinine kinase Risk of renal failure (myoglobulinaemia)

Question 37

What are the 3 stages of acut limb ischemia?

Answer 37

I - Viable (audible art and venous doppler) II - Threatened (inaudible art doppler, audible venous) III - Irreversiable (inaudible art and venous doppler)

Question 38

Treatment options: Salvagable limb - ebulus? Thrombus? Non-Salvagable? Fit/willing for amputation?

Answer 38

``` Salavagavgle : Embolus - embolectomy Thrombus - consider endovascular (thrombectomy/thrombolysis) or open embolectomy (w/wo bypass) Non salvageable: Fit/willing for amputation - amputation Not - palliate ```

Question 39

What % ALI embolic/thrombotic?

Answer 39

30% embolic, 60% thrombosis

Question 40

How long does it take for irreversiable muscle ischemia?

Answer 40

6-8h

Question 41

Is ALI a medical emergency?

Answer 41

Yes

Question 42

What is Diabetic foot disease? How prevelent? What % require amputation?

Answer 42

Ulcers on foot as result of diabetes. 25% all diabetics will get ulcers, 50% become infected, 20% require amputation

Question 43

What are the major contributing factor to ulcers? How best to prevent?

Answer 43

``` Microvascular peripheral artery disease Peripheral neuropathy Mechanical imbalance Foot deformity Minor trauma Susceptibility to infection ``` Prevent: Always wear shoes – avoid minor injuries Check fit of footwear Check pressure points/plantar surface of foot regularly Prompt and regular wound care of skin breaches Effective glycaemic control

Question 44

Management of diabetic foot disease?

Answer 44

``` Antibiotics asap Maggots (larvae therapy) Negative pressure (shown to be best) skin grafts dressings Amputation/revascularisation ```

Question 45

Where are 2 major sites of amputation?

Answer 45

Above and below the knee