Peripheral arterial disease

Question 1

What is peripheral arterial disease?

Answer 1

Narrowing of the arteries supplying the limbs + peripheries hence reducing blood supply.

Question 2

What is the main symptom of peripheral arterial disease?

Answer 2

Claudication - intermittent crampy, aching pain in the leg that occurs on exertion.

Question 3

What is critical limb ischaemia?

Answer 3

End stage peripheral arterial disease

Inadequate blood supply at rest

Question 4

How does critical / chronic limb ischaemia present?

Answer 4

6 Ps - 
Pain
Pallor
Pulselessness
Paralysis
Paraesthesia / pins + needlse
Perishing cold

Also with ulcers and gangrene

Question 5

What is the main cause of acute limb ischaemia?

Answer 5

A thrombus (clot) blocks the arterial supply of the distal limb - this may have embolised from elsewhere

Question 6

What is the difference between necrosis and gangrene?

Answer 6

Both refer to death of tissue, but gangrene is specifically due to inadequate blood supply.

Question 7

What is ischaemia?

Answer 7

inadequate oxygen to tissue due to reduced blood supply.

Question 8

What is atherosclerosis?

Answer 8

Thickening + stiffening of arteries due a build up of plaques in the walls (fatty deposits /lipids)

Question 9

What are some risk factors for atherosclerosis?

Answer 9

Old age
Family history
Male
Smoking
High alcohol intake
Poor diet - high in sugar + trans fats
Sedentary lifestyle
Obesity
Stress

Question 10

What are some complications of atherosclerosis?

Answer 10

Angina
MI (heart attack)
TIA
stroke
Peripheral arterial disease
Chronic mesenteric ischaemia

Question 11

What is Leriche Syndrome and how does it present?

Answer 11

Occlusion of the distal aorta / proximal common iliac artery.
Presents with
- thigh/buttock claudication
- absent femoral pulses
- male impotence

Question 12

What are some signs of arterial disease on inspection?

Answer 12

Skin pallor
Cyanosis
Muscle wasting
Hair loss
Ulcers
Poor wound healing
Gangrene

Question 13

What may be seen on examination in arterial disease?

Answer 13

Reduced skin temperature
Reduced sensation (parasthesia)
Prolonged capilliary refill (> 2 seconds)

Question 14

What causes arterial ulcers?

Answer 14

Ischaemia secondary to an inadequate blood supply

Question 15

What causes venous ulcers?

Answer 15

Impaired drainage and pooling of blood

Question 16

What investigations are used for diagnosing peripheral arterial disease?

Answer 16

Bloods - serum lactate to assess level of ischaemia
Ankle-brachial pressure index
Duplex ultrasound - shows the speed and volume of blood flow
Angiography (CT or MRI) - using contrast

Question 17

What is ankle brachial pressure index and what do the results indicate?

Answer 17

A ratio of systolic blood pressure in the ankle compared to the arm.
0.9 - 1.3 is normal
0.6 - 0.9 - mild peripheral arterial disease
0.3 - 0.6 - moderate - severe peripheral arterial disease
Less than 0.3 - severe disease and critical ischaemia

Question 18

What are the management options for intermittent claudication?

Answer 18

Lifestyle changes - e.g. stop smoking, control diabetes
Exercise training
Medical treatments - atorvastatin, clopidogrel and naftidrofurly oxalate (acts as a peripheral vasodilator)
Surgery

Question 19

What are the surgical options for managing intermittent claudication?

Answer 19

Endovascular angioplasty + stenting
Endardectomy - cutting vessel open + removing atherosclerotic plaque
Bypass surgery

Question 20

What is the management for critical limb ischaemia?

Answer 20

Endovascular angioplasty + stenting
Endardectomy
Bypass surgery
Amputation

Question 21

How is acute limb ischaemia managed?

Answer 21

Heparin (bolus then infusion - even if before surgery)
Endovascular thrombolysis
Endovascular thrombectomy
Surgical thrombectomy
Endardectomy
Bypass surgery
Amputation

Question 22

What is the long term management after acute limb ischaemia?

Answer 22

Reduction of CVD risk
- regular exercise
- smoking cessation
- weight loss
Anti platelet therapy - low dose aspirin or clopidogrel
If amputated will need physio + long term rehab plan

Question 23

What are the complications of acute limb ischaemia?

Answer 23

Mortality rate - around 20%

Reperfusion injury –> compartment syndrome and electrolyte imbalances

Amputation / loss of limb (and complications of this surgery)

Question 24

What are risk factors for chronic / critical limb ischaemia?

Answer 24

Smoking
Diabetes mellitus
Hypertension
Hyperlipidaemia
Increasing age
Family history
Obesity
Physical inactivity

Question 25

What specific test can be use to test for critical limb ischaemia?

Answer 25

Buerger’s test

involves lying the patient down and raising their legs until the go pale. Then lower them down until the colour comes back. The angle at which the limb goes pale is Buerger’s angle (less than 20 indicates severe ischaemia)

Question 26

What are the complications of critical / chronic limb ischaemia?

Answer 26

Sepsis (infected gangrene)
Acute on chronic ischaemia
Amputation
Reduced mobility + quality of life.
5 year mortality is around 50%