Chronic limb ischaemia

Question 1

Describe chronic limb ischaemia?

Answer 1

• Peripheral arterial disease
  
  • Resulting in symptomatic reduced blood to the limbs
• Typically due to atherosclerosis and in the lower limbs
  
  • ULs and gluteals sometimes

Question 2

What are the risk factors for chronic limb ischaemia?

Answer 2

• Smoking
• DM
• HTN
• Hyperlipidaemia

Question 3

What are the clinical features of Chronic limb ischaemia?

Answer 3

• Fontaine classification
  
  • Stage 1: Asymptomatic
  • Stage 2: Intermittent claudication
  • Stage 3: Ischaemic rest pain
  • Stage 4: Ulceration, gangrene or both

Question 4

Name a diagnostic test for chronic limb ischaemia?

Answer 4

• Buerger’s test
  
  • Lie patient supine and raise their legs until they go pale
  • Lower them until colour returns (there may be hyperaemia)
  • Buerger’s angle: the angle where the limb goes pale
    
    • Less than 20^o indicates severe ischaemia

Question 5

What is Leriche syndrome?

Answer 5

• Peripheral arterial disease affecting aortic bifurcation
• Presents with buttock/thigh pain + erectile dysfunction

Question 6

Describe Critical limb ischaemia?

Answer 6

• Advanced form of chronic limb ischaemia
• Clinically defined in 3 ways:
  
  • Ischaemic rest pain >2weeks, requiring opiates
  • Ischaemic lesions or gangrene
  • ABPI <0.5
• Limbs pale and cold, + weak/absent pulses

Question 7

What are the differentials for some presenting with limb ischmia symptoms?

Answer 7

• Spinal stenosis (neurogenic claudication)
• Acute limb ischaemia
  
  • Features less than 14 days, symptom onset within hours

Question 8

Describe spinal stenosis?

Answer 8

• Pain in back radiating down lateral leg (tensor fascia lata)
• Symptoms on initial movement, relieved by sitting

Question 9

Describe Acute-on-chronic limb ischaemia?

Answer 9

• Acute, often embolic, event occurs
• Patient has previous peripheral vascular disease

Question 10

Describe the diagnosis of chronic limb ischaemia?

Answer 10

• Clinical diagnosis
• Confirmed with ABPI
• Doppler US
  
  • severity and location
• CT angiography

Question 11

Describe the relevance of ABPI in Chronic limb ischaemia?

Answer 11

Question 12

Describe the management of Chronic limb ischaemia?

Answer 12

• Medical
  
  • Lifestyle advice
  • Atorvastatin (80mg OD)
  • Clopidogrel (75mg OD)
• Supervised exercise programme may help claudication
• Surgery

Question 13

When would surgery be used in chronic limb ischaemia?

Answer 13

• Risk factor modification has been discussed
• Supervised exercise showed no improvement
• Patients with critical limb ischaemia

Question 14

Describe the use of surgery in Chronic limb ischaemia?

Answer 14

• Angioplasty (w/ or wo/ stenting)
• Bypass grafting (younger patients)
• Amputation

Question 15

Describe the complications of Chronic limb ischaemia?

Answer 15

• Sepsis (sec to infected gangrene)
• Acute-on-chronic ischaemia
• Amputation
• Reduced mobility and QoL

Question 16

Key points of Chronic limb ischaemia?

Answer 16

• Clinical diagnosis, quantified by ABPI testing then angiogram imaging
• Surgery if conservative mangement fails or critical limb ischaemia
• 5 year mortality is 50% in those diagnosed with chronic limb ischaemia

Question 17

Describe the relationship between homocysteine and chronic limb ischaemia?

Answer 17

• Homocysteine is an amino acid gained from eating meat
• Lower homocysteine => reduced risk of CV events