Peripheral Arterial Disease

Question 1

List the pulse points of the body that should be palpated during a cardiac examination

Answer 1

1. Radial
2. Brachial
3. carotid
4. Femoral
5. Popliteal
6. Posterior tibial
7. Dorsalis pedis

Question 2

What is the main cause of chronic limb ischaeia?

Answer 2

Atherosclerotic disease of the arteries supplying the lower limb

Question 3

What are the 2 less common causes of chronic lower limb ischaemia?

Answer 3

1. Vasculitis

2. Buerger’s Diseases

Question 4

List the 5 main risk factors associated with chronic limb ischaemia

Answer 4

1. Male
2. Age
3. Smoking
4. Hypercholesterolemia
5. Hypertension
6. Diabetes

Question 5

Name the classification system used to stage chronic limb ischaemia

Answer 5

The Fontaine classification

Question 6

Explain each stage of the Fontaine Classification

Answer 6

Stage I-Asymptomatic, incomplete blood vessel obstruction

Stage IIA- Mild claudication pain in limb when walking a distance of greater than 200 meters

Stage IIB- Mild claudication pain in limb when walking a distance of less than 200 meters

Stage III (critical)- Rest pain, mostly in the feet

Stage IV (critical)- Necrosis and/or gangrene of the limb

Question 7

What examination findings might you notice in somebody with chronic limb ischaemia?

Answer 7

Ulceration, Pallor & Hair loss in the leg

Differences in temperature, capillary refill, peripheral sensation and pulses between the two legs

Question 8

What is the first line investigation into chronic limb ischaemia?

Answer 8

Duplex scan or CTA/MRIa

Question 9

What are 2 advantages and 2 disadvantages of a duplex scan?

Answer 9

Advantages:

1. Dynamic
2. No radiation or contrast

Disadvantages:

1. Not useful in the abdomen
2. Operator dependent, time consuming

Question 10

Name the tests/investigations that can be conducted in patients with suspected chronic limb ischaemia

Answer 10

Tests:

1. Ankle Brachial Pressure Index
2. Buerger’s test

Investigations:

1. Duplex scan
2. CTA/MRIa
3. Digital subtraction angiography

Question 11

Describe how the ankle brachial pressure index corresponds to the severity of chronic limb ischaemia

Answer 11

Ankle pressure (mmHg) / brachial pressure (mmHg)

> 1 = no symptoms

0. 95-0.5 = Intermittent claudication
1. 5-0.3 = Rest pain

<0.2 = gangrene and ulceration

Question 12

Describe Brueger’s Test

Answer 12

Elevate the legs
and look for Pallor & Buerger’s Angle (< 20 degrees severe ischaemia)

THEN

Hang feet over edge of bed and look for: Slow to regain colour & a dark red colour (hyperaemic sunset foot)

Question 13

What happens during Digital subtraction angiography?

Answer 13

Stents are fitted in the damaged vessel

Question 14

How should patients with chronic limb ischaemia be managed?

Answer 14

in the same way as those with coronary artery disease!

1. Antiplatelets & statins
2. Target BP. <140/85
3. Smoking cessation, diabetic control and increased exercise
4. Open surgery (bypass and/or endarterectomy)

Question 15

What are the risk factors associated with open surgical management of a patient with chronic limb ischaemia?

Answer 15

Bleeding, wound infection, pain, scar, DVT, PE, MI, CVA, LRTI, death, damage to nearby vein, artery, nerve, distal emboli, graft failure

Question 16

What is the re-intervention rate of patients with chronic limb ischaemia?

Answer 16

18.3-38.8%

Question 17

What is the name of the trial which looked at chronic limb ischaemia patient outcomes between angioplasty or surgery?

Answer 17

The BASIL trial

Question 18

What were the main findings of the BASIL trial?

Answer 18

If short-term results are what matter angioplasty is the likely preferred strategy.

However, in patients with suitable anatomy, vein availability and a reasonable life expectancy, surgery may be better for greater long-term durability.

Question 19

What is the difference between chronic and acute limb ischamia?

Answer 19

Chronic= caused usually by an atheroma in the peripheral arteries and develops over a long perid of time

Acute= Caused by an embolus or a thrombus (NOT A DVT!) and is a medical emergency

Question 20

What % of acute limb ischaemia cases are caused by A) Embolus and B) Thrombus

Answer 20

A) 30%

B) 60%

Question 21

What are some of the common causes of acute limb ischaemia

Answer 21

Arterial embolus such as MI, AF or proximal atherosclerosis

Thrombus from a previously diseased artery

Trauma

Dissection

Acute aneurism

Question 22

What are the clinical features of acute limb ischaemia? (The 6 P’s)

Answer 22

1. Pain
2. Pallor
3. Pulse Deficit
4. Paraesthesia
5. Paresis/Paralysis
6. Poikilothermia (cold)

Compare to contralateral limb

Question 23

When does acute limb ischaemia become irreversible?

Answer 23

After 6-8 hours (this is when it is then classed as compartment syndrome)

Question 24

What are the features of compartment syndrome?

Answer 24

• Inflammation
• Oedema
• venous obstruction
• Rise in creatinine kinase
• Risk of renal failure (myoglobulinaemia)

Question 25

How is acute limb ischaemia managed if it has been caused by an embolus and the limb is still salvageable?

Answer 25

Embolectomy

Question 26

How is acute limb ischaemia managed if it has been caused by an thrombus and the limb is still salvageable?

Answer 26

Endovascular mechanical thrombectomy or thrombolysis

Question 27

How should a patient with acute limb ischaemia be managed if the limb cannot be salvaged?

Answer 27

If possible, amputate, if not palliate

Question 28

What % of diabetic patients will develop a foot ulcer in their lifetime?

Answer 28

25%

Question 29

What % of diabetic foot ulcers become infected?

Answer 29

50%

Question 30

What % of diabetic foot ulcers result in amputation?

Answer 30

20%

Question 31

What 6 factors contribute to the formation of a diabetic foot ulcer?

Answer 31

1. microvascular peripheral artery disease 2. Peripheral neuropathy 3. Mechanical imbalance 4. Foot deformity 5. Minor trauma 6. Susceptibility to infection

Question 32

What measures can be taken to avoid the development of a diabetic foot ulcer?

Answer 32

1. Always wear shoes 2. Check the fit of footwear 3. Check pressure points and the underside of the foot regularly 4. Take care of skin breaches on the foot 5. Control blood sugars!!

Question 33

How is a diabetic foot ulcer managed?

Answer 33

1. Prevention 2. Careful wound management 3. Consider systemic antibiotics if there is a possiblity of infection 4. Investigate for osteomyelitis, gas gangrene, necrotizing fasciitis 5. Revascularise distal disease 6. Amputation if appropriate 7. Dressings 8. Debridement 9. Negative pressure wound closure 10. Skin grafts