Limb Ischaemia & DVT

Question 1

What is the key clinical feature of chronic limb ischaemia (i.e. peripheral arterial disease)? What is meant by this?

Answer 1

Intermittent claudication: calf/leg/buttock pain which occurs after a predictable amount of exercise, and settles with rest

Question 2

The development of what symptom suggests that chronic limb ischaemia has progressed to critical limb ischaemia?

Answer 2

Severe ischaemic pain at rest

Question 3

What are some complications of critical limb ischaemia?

Answer 3

Ulceration and/or gangrene

Question 4

What investigation is used to diagnose and assess severity of chronic limb ischaemia?

Answer 4

ABPI calculation

Question 5

What ABPI score would indicate intermittent claudication?

Answer 5

0.5 - 0.95

Question 6

What ABPI score would indicate ischaemic pain at rest?

Answer 6

0.3 - 0.5

Question 7

What ABPI score would indicate gangrene and ulceration?

Answer 7

< 0.2

Question 8

What investigation is most useful in chronic limb ischaemia for confirming an occlusion?

Answer 8

Duplex US

Question 9

What investigation is most useful in chronic limb ischaemia for surgical planning?

Answer 9

MR angiography

Question 10

Most management of chronic limb ischaemia is conservative, and involves management of risk factors. When would interventional management be considered?

Answer 10

If symptoms are disabling, or if critical limb ischaemia occurs

Question 11

What are some interventional management options for chronic limb ischaemia? If a patient isn’t suitable for these options, what should be done?

Answer 11

Angioplasty and stenting, resection or bypass grafting - if these can’t be done then amputation is necessary

Question 12

What is acute limb ischaemia?

Answer 12

The sudden loss of blood supply to a limb

Question 13

What are the two main causes of acute limb ischaemia? How common is each?

Answer 13

Thrombus formation from an existing atherosclerotic plaque (80%), or embolism, usually in AF (15%)

Question 14

What are the 6Ps of acute limb ischaemia?

Answer 14

Pain, pallor, paraesthesia, perishingly cold, pulseless, paralysis

Question 15

What investigations can be used to locate the occlusion in acute limb ischaemia?

Answer 15

Duplex US or CT

Question 16

Describe the management options for acute limb ischaemia?

Answer 16

Thrombolysis, embolectomy, bypass surgery

Question 17

What are some complications of acute limb ischaemia?

Answer 17

Irreversible ischaemia, gangrene, compartment syndrome

Question 18

What condition may cause the ABPI to be falsely elevated, even with significant vascular disease?

Answer 18

Diabetes

Question 19

What are some risk factors for DVT due to them causing stasis of blood flow?

Answer 19

Immobility, varicose veins, compression

Question 20

What are some risk factors for DVT due to them causing hypercoagulability of blood?

Answer 20

Pregnancy, malignancy, inflammation, smoking, thrombophilias

Question 21

What are some risk factors for DVT due to them causing endothelial damage?

Answer 21

Trauma and surgery

Question 22

How can DVT be prevented in hospital patients?

Answer 22

LMWH injections and compression stockings

Question 23

Half of cases of DVT are asymptomatic. How do they present if they are symptomatic?

Answer 23

Red, hot, swollen, tender calf

Question 24

What are some differentials of a DVT?

Answer 24

Cellulitis, trauma, ruptured Baker’s cyst

Question 25

What is the name of the scoring system used to assess the likelihood that a patient has a DVT?

Answer 25

Well's score

Question 26

A Well's score of 3 or more suggests a 50% likelihood of DVT. What investigation is required?

Answer 26

Duplex US

Question 27

A Well's score of 2 or less suggests a 5-20% likelihood of DVT. What investigation is required?

Answer 27

D-Dimer

Question 28

In all patients, regardless of Well's score, what investigation investigation should be done if a D-Dimer comes back positive?

Answer 28

Duplex US

Question 29

Describe the initial management of a DVT?

Answer 29

Therapeutic dose LMWH while receiving loading doses of warfarin, until the INR is within an acceptable range

Question 30

How long should warfarin be given for after a DVT?

Answer 30

3-6 months

Question 31

What are some potential complications of a DVT?

Answer 31

PE, post-thrombotic syndrome, venous ulcers

Question 32

What are some signs of chronic venous insufficiency?

Answer 32

Leg swelling, increased pigmentation, lipodermatosclerosis, eczema and ulceration

Question 33

What is the investigation of choice for confirming venous insufficiency?

Answer 33

Duplex US

Question 34

What is the most common management option for chronic venous insuffiency?

Answer 34

Compression stockings

Question 35

What is the gold standard investigation for diagnosing varicose veins?

Answer 35

Duplex US

Question 36

When should patients with varicose veins be referred to surgery?

Answer 36

If they are symptomatic / if there are any skin changes

Question 37

What medication is used to manage primary Raynaud's?

Answer 37

Ca channel blockers