Chronic limb ischaemia

Question 1

Evidence of critical limb ischaemia?

Answer 1

tissue loss, ulcers, rest pain

Question 2

Which test can illicit rest pain?

Answer 2

Beurger’s test. With the patient supine, elevate both legs to an angle of 45 degrees and hold for one to two minutes. Observe the color of the feet. Pallor indicates ischaemia. It occurs when the peripheral arterial pressure is inadequate to overcome the effects of gravity.

Question 3

Order nerves, muscles, skin, in order of which is affected first due to arterial insufficiency?

Answer 3

skin>nerves>muscle (nerves are the most important)

Question 4

What are the risk factors for chronic limb ischaemia?

Answer 4

smoking, diabetes, hypertension, hyperlipidaemia, old age (similar for acute limb ischaemia)

Question 5

Name four symptoms/signs of chronic limb ischaemia

Answer 5

1. Claudication
2. Rest pain (worse at night)
3. Arterial ulcer- painful
4. Tissue loss
5. Gangrene

Question 6

How is chronic limb ischaemia diagnosed?

Answer 6

history, exam, arterial/brachial pressure index, angiogram, doppler ultrasound

Question 7

What is the management of chronic ischaemia?

Answer 7

1. Conservative: stop smoking, exercise, BP control, antiplatelet drugs
2. Angiography, stent
3. Surgical- bypass vessel above obstruction to vessel below
4. Amputation

Question 8

Which combination bypasses are typically performed in chronic limb ischaemia?

Answer 8

aorto-femoral, femoral-popliteal, axillo-femoral, femoral-femoral

Question 9

What is the number one cause of chronic limb ischaemia?

Answer 9

atherosclerosis

Question 10

Which is the most important bedside exam in assessing limb viability?

Answer 10

buerger’s test

Question 11

Explain a positive buerger’s test

Answer 11

positive when foot rubor reduces with elevation and returns upon dependency. Cellultici foot will not blanch when elevated, therefore negative test for cellulitis

Question 12

Which staging system is used to score chronic ischaemia?

Answer 12

rutherford classification, 6 stages for chronic while 4 stages for acute.

Question 13

Chronic limb ischaemia rutherford stage 3. Is there serious tissue threat/loss?

Answer 13

stage 3= severe claudication. For acute, stage III would be complete loss of motor and sensory function

Question 14

Acute ishaemic limb rutherford stage 3. What is the management for this?

Answer 14

amputation

Question 15

What are complications of surgery?

Answer 15

Procedural: bleeding, infection, risk of worsening +amputation
Long term/general: respiratory compromise, MI, AKI, stroke
Specific: delayed healing

Question 16

31 year old man with blue fingers and toes. He is a heavy smoker. What is the diagnosis?

Answer 16

thromboangiitis obliterans (also known as Buerger disease). The key presentation to remember for your exams is a young male smoker with painful blue fingertips. The exam question may ask the diagnosis or ask the most important aspect of management (completely stopping smoking).