Arterial Diseases of the Limbs

Question 1

describe stage one of the fontaine classification

Answer 1

asymptomatic, incomplete blood vessel obstruction

Question 2

describe stage 2 of the fontaine classification

Answer 2

A: claudication when walking a distance of greater than 200m
B: claudication when walking a distance less than 200m

Question 3

describe stage 3 of the fontaine classification

Answer 3

rest pain in the feet

Question 4

describe stage 4 of the fontaine classification

Answer 4

necrosis and/or gangrene

Question 5

what signs of chronic ischaemia would you see when examining the legs?

Answer 5

> ulceration (tissue loss)
pallor
hair loss

Question 6

what is an ankle brachial index?

Answer 6

the ankle pressure divided by the brachial pressure

Question 7

describe the buergers test

Answer 7

the legs are elevated, if they become pale at an angle of less than 20 degrees then there is severe ischaemia.
the feet are hung over the edge of the bed, there is a slow regain of colour creating a dark red colour, hyperaemic.

Question 8

what do anti-platelets do?

Answer 8

they reduce the risk of requiring revascularisation as well as reducing cardiovascular mortality

Question 9

what are the effects of statins?

Answer 9

they inhibit antiplatelet activation and thrombosis, endothelial and inflammation activation, and plaque rupture.

Question 10

what is the management?

Answer 10

> antiplatelet
> statins
> blood pressure control
> smoking cessation
> exercise
> diabetic control

Question 11

what imaging investigations would you carry out?

Answer 11

> duplex
CT/MRA
digital subtraction angiogram

Question 12

what are the pros of a duplex imaging?

Answer 12

> dynamic

> no contrast or radiation needed

Question 13

what are the problems with duplex imaging?

Answer 13

> not good on the abdomen
operator dependant
time consuming

Question 14

what are the pros of CTA/MRA imaging?

Answer 14

detailed allows treatment planning

Question 15

what are the problems the CTA/MRA imaging?

Answer 15

> contrast and radiation

> can overestimate calcification

Question 16

if an angioplasty has been tried and it has failed what might you try next?

Answer 16

surgical bypass of the occlusion/stenosis

Question 17

what does a surgical bypass require?

Answer 17

> inflow
conduit: autologous (veins form legs/arms) or synthetic
outflow

Question 18

what are the technical complications of a surgical bypass?

Answer 18

> damage to nearby vein, artery, nerve
distal emboli
graft fracture

Question 19

define thrombus

Answer 19

blood clot formed in situ within the vascular system of the body and impeding blood flow

Question 20

what can cause acute limb ischaemia?

Answer 20

> arterial embolus
> thrombosis
> trauma
> dissection
> acute aneurysm thrombosis

Question 21

what are the 6 p’s in the presentation of acute limb ischaemia?

Answer 21

> pain
> pallor
> perishingly cold
> paraesthesia
> paralysis
> pulseless

Question 22

when will irreversibility of acute limb ischaemia start?

Answer 22

after 6 hours

Question 23

describe compartment syndrome of muscle ischaemia

Answer 23

there is inflammation but the fascia stops expansion resulting in oedema and venous obstruction. this becomes a cycle where the tissue dies. there is a rise in creatinine and a risk of renal failure.

Question 24

what is the management of acute limb ischaemia?

Answer 24

> analgesia
anticoagulate
pain killer
heparin

Question 25

what are the management option in ALI where there is a suspicion of thrombosis in situ?

Answer 25

> endovascular mechanical thrombectomy

> open embolectomy

Question 26

in acute limb ischaemia what is the mortality rate of amputation?

Answer 26

20%

Question 27

what percentage of diabetic will develop foot ulcer in their life?

Answer 27

15%

Question 28

what foot-care is recommended to avoid diabetic foot disease?

Answer 28

> always wear shoes
check fit of the foot wear
check pressure points of the foot
prompt and regular wound care of skin breaches

Question 29

what are the options for management of diabetic foot disease?

Answer 29

> revascularisation: distal crural angioplasty/stent in distal disease
amputation