peripheral arterial disease

Question 1

is critical limb ischaemia the same disease process as coronary and carotid atherosclerotic disease?

Answer 1

yes

Question 2

what are the risk factos for critical limb ischaemia?

Answer 2

Male
Age
Smoking
Hypercholesterolemia
Hypertension
Diabetes

Question 3

what is the first stage of critical limb ischaemia?

Answer 3

Asymptomatic, incomplete blood vessel obstruction

Question 4

what is the second stage of critical limb ischaemia?

Answer 4

Mild claudication pain in limb

Stage IIA: Claudication when walking a distance of greater than 200 meters

Stage IIB: Claudication when walking a distance of less than 200 meters

Question 5

what is the third stage of critical limb ischaemia?

Answer 5

Rest pain, mostly in the feet

Question 6

what is the fourthstage of critical limb ischaemia?

Answer 6

Necrosis and/or gangrene of the limb

Question 7

what type of questions should you ask in a history?

Answer 7

Claudication: Exercise tolerance, effect of incline, change over time, relieved by rest? Where in the leg, type of pain. Bilateral?
Rest pain: Type of pain, relieving factors
Tissue loss: Duration, history of trauma, peripheral sensation

Risk factors
Past Medical History
Drug History
Occupational History – Daily Habits
Surgical History

Question 8

what are signs of chronic ischaemia on the legs?

Answer 8

Ulceration
Pallor
Hair loss

Question 9

what things would you feel for when examining a patient with chronic ischaemia?

Answer 9

Temperature
Capillary refill time
Peripheral sensation
Pulses – start at the aorta

Question 10

what examinations would you do for chronic ischaemia?

Answer 10

Ankle Brachial Pressure Index

Buerger’s test

Question 11

what imaging would you do for a patient with chronic ischaemia?

Answer 11

Duplex
CTA/MRA
Digital subtraction angiography

Question 12

what is buergers test?

Answer 12

Elevate legs
Pallor 
Buerger’s Angle < 20 degrees severe ischaemia
Hang feet over edge of bed
Slow to regain colour
Dark red colour (hyperaemic sunset foot)

Question 13

with what other condition should peripheral artery disease be managed with the same way?

Answer 13

coronary artery disease

Question 14

whats the best medical therapy for peripheral artery disease

Answer 14

Combination of
Antiplatelet: Reduces risk of requiring revascularization as well as cardiovascular and all-cause mortality

Statin: Inhibits platelet activation and thrombosis, endothelial and inflammation activation, plaque rupture

Question 15

what are the risk factor control for managing peripheral artery disease?

Answer 15

BP control: Target <140/85
Smoking cessation: Excess risk of cardiovascular disease diminishes within 4-6yrs
Diabetic control: 10% of PAD patients are undiagnosed diabetics. Tight glycaemic control prevents microvascular disease
Exercise: 150% improvement in walking time

Question 16

what open surgery would you fo on a pateint with peripheral artery disease?

Answer 16

Bypass and/or

Endarterectomy

Question 17

what endovascularintervention would you do on a patient with PAD?

Answer 17

Balloon angioplasty
Stent placement
Atherectomy

Question 18

what does a surgical bypass require?

Answer 18

inflow
a conduit
outflow

Question 19

what are complications of surgical bypass?

Answer 19

General: Bleeding, wound infection, pain, scar, DVT, PE, MI, CVA, LRTI, death (2%)
Technical: Damage to nearby vein, artery, nerve, distal emboli, graft failure (stenosis, occlusion)

Question 20

whats an embolus?

Answer 20

a blood clot, air bubble, piece of fatty deposit, or other object which has been carried in the bloodstream to lodge in a vessel and cause an obstruction.

Question 21

whats a thrombus?

Answer 21

: a blood clot formed in situ within the vascular system of the body and impeding blood flow.

Question 22

whats the pathophysiology of acute limb ischaemia?

Answer 22

Arterial embolus: MI, AF, proximal atherosclerosis (NOT DVT/PE)
Thrombosis: Usually thrombosis of a previously diseased artery.
Trauma
Dissection
Acute aneurysm thrombosis i.e. popliteal

Question 23

what are the 6 Ps of clinical presentation of acute limb ischaemia?

Answer 23

Pain
Pallor
Pulse Deficit
Paraesthesia
Paresis/Paralysis
Poikilothermia (cold)
Compare to contralateral limb

Question 24

what should you consider for the jistroy of a patient with acute limb ischaemia?

Answer 24

Cardiac history
Onset/duration of symptoms 
History of chronic limb ischaemia
Risk factors for CLI
Functional status

Question 25

what should you do wjen a patient has an ambolus?

Answer 25

embolectomy

Question 26

what should you do wjen patient has suspected thrombus in situ

Answer 26

endovascular mechanical thromboectomy/thrombolysis

open embolectomy +/- bypass

Question 27

what should you do if limb is non salvagable?

Answer 27

amputation or palliate

Question 28

Pathophysiology of diabetic foot disease?

Answer 28

Microvascular peripheral artery disease
Peripheral neuropathy
Mechanical imbalance
Foot deformity
Minor trauma 
Susceptibility to infection

Question 29

how would someone prevent diabetic foot ulcers?

Answer 29

Always wear shoes – avoid minor injuries
Check fit of footwear
Check pressure points/plantar surface of foot regularly
Prompt and regular wound care of skin breaches

Effective glycaemic control

Question 30

how do you manage diabetic foot disease/ulcers?

Answer 30

Prevention
Diligent wound care
Infection – consider systemic antibiotics
Investigate for osteomyelitis, gas gangrene, necrotizing fasciitis

Question 31

how else would you manage diabetic foot disease?

Answer 31

Revascularization – Very distal disease
Attempt distal crural angioplasty / stent
Distal bypass

Amputation