Arterial diseases of the limbs

Question 1

What is the pathophysiology of peripheral vascular disease ?

Answer 1

Atherosclerotic disease of arteries supplying the lower limb
Less commonly: vasculitis, Buerger’s disease
Same disease process as cornoary and carotid atherosclerotic disease

Question 2

What is the risk factors of PVD ?

Answer 2

Male
Age
Smoking
Hypercholesterolemia 
Hypertension
Diabetes

Question 3

How are the symptoms of PVD classified ?

Answer 3

Fontaine classification

Question 4

What is stage I on Fontaine classification ?

Answer 4

Asymptomatic, incomplete blood vessel obstruction

Question 5

What is stage II on Fontaine classification ?

Answer 5

Mild claudication pain in limb
Stage IIA: claudication when walking a distance >200m
Stage IIB: claudication when walking a distance <200m

Question 6

What is stage III on Fontaine classification ?

Answer 6

Rest pain, mostly in the feet

Question 7

What is stage IV on Fontaine classification ?

Answer 7

Necrosis and gangrene of the limb

Question 8

What is useful in the history of PVD ?

Answer 8

Claudication 
Rest pain
Tissue loss
Risk factors
Past medical history
Surgical history

Question 9

What should we look for on examination of PVD ?

Answer 9

Signs of chronic ischaemia:

• ulceration
• pallor
• hair loss

Question 10

What should we feel for on examination of PVD ?

Answer 10

Temperature
Capillary refill time
Peripheral sensation
Pulses- start at aorta

Question 11

What should we auscultate on examination of PVD ?

Answer 11

Hand help doppler

Dorsalis pedis and posterior tibial pulses

Question 12

What are special tests for PVD ?

Answer 12

Ankle brachial pressure index

Buerger’s test

Question 13

What are the investigations for PVD ?

Answer 13

Duplex:
	 - dynamic 
	 - no radiation/ contrast 
	  - not good in abdomen
CTA/MRA:
	  - detailed- allows treatment planning 
	  - first line according to NICE 
	  - contrast and radiation 
Digital subtraction angiography

Question 14

What is the best medical therapy of PVD ?

Answer 14

Combination of:
- antiplatelet- reduces risk of requiring revascularisation as well as CV
mortality
- statin- inhibits platelet activation and thrombosis, lowers cholesterol

Question 15

How should we control the risk factors in PVD ?

Answer 15

BP control
Smoking cessation
Diabetic control

Question 16

What surgery can be used for PVD ?

Answer 16

Bypass and or endarterectomy

Question 17

What is endovascular intervention ?

Answer 17

Balloon angioplasty
Stent placement
Atherectomy

Question 18

What is acute limb ischamia ?

Answer 18

Embolis carried in blood stream and lodges in a vessel causing obstruction

Question 19

What is the pathophysiology of acute limb ischaemia ?

Answer 19

Arterial embolus- MI, AF 
Thrombosis 
Trauma 
Dissection
Acute aneurysm
Thrombosis

Question 20

What is the clinical presentation of acute limb ischaemia ?

Answer 20

Pain
Pallor
Pulse deficit
Paraesthesia 
Paresis/paralysis 
Poikilothermia (cold)
Compare to contralateral limb

Question 21

What is useful in the history of acute limb ischaemia ?

Answer 21

Cardiac history
Onset/duration of symptoms
History of chronic limb ischamia 
Risk factors for CLI 
Functional status

Question 22

What is compartment syndrome ?

Answer 22

Muscle ischaemia 
Inflammation, oedema, venous obstruction
Tense, tender calf
Rise in creatinine kinase 
Risk of renal failure

Question 23

What % of diabetics will develop diabetic foot disease/ ulcer ?

Answer 23

25%

Question 24

What % of DFU become infected ?

Answer 24

50%

Question 25

What % of DFD require amputation ?

Answer 25

20%

Question 26

What is the pathophysiology of diabetic foot disease ?

Answer 26

Microvascular peripheral artery disease
Peripheral neuropathy
Mechanical imbalance 
Foot deformity 
Minor trauma 
Susceptibility to infection

Question 27

How can DFD be prevented ?

Answer 27

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 28

What is the management of DFD ?

Answer 28

Prevention
Diligent wound care 
Infection-> systemic antibiotics 
Investigate for osteomyelitis, gas gangrene, necrotising fasciitis
Revascularisation- very distal disease
Amputation
Dressings
Debridement- larval therapy  
Negative pressure wound closure
Skin grafts