Peripheral arterial disease

Question 1

Define PAD.

Answer 1

Range of arterial syndromes that are caused by atherosclerosis obstruction of the lower extremity arteries.

Question 2

Which staging and categorisation system is used in PAD?

Answer 2

Fontaine stages (Intermittent Claudication) and Rutherford categories.

Question 3

What is the epidemiology of PAD?

Answer 3

· Prevalence increases with age.

· Equal between men and women.

Question 4

What is the pathophysiology of PAD?

Answer 4

· Damage, inflammation and structural defects of blood vessels.

· Atherosclerosis, degenerative diseases, dysplastic disorders, vascular inflammation and thrombosis.

· Pathophysiology of intermittent claudication:

• Haemodynamic compromise.
• Deconditioning, metabolic changes.
• Impaired synthesis of phosphocreatine.

Question 5

What is the aetiology of PAD?

Answer 5

· Most commonly caused by atherosclerosis.

· Rarer causes are:

• Aortic coarctation.
• Arterial tumour.
• Arterial dissection.
• Temporal arteritis.

Question 6

List the common risk factors related to PAD.

Answer 6

· Smoking. 
· Diabetes.
· HTN. 
· Hyperlipidaemia.
· Age >40 years.
· History of CAD/cerebrovascular disease. 
· Low levels of exercise. 
· Virchow's triad:
 - Hypercoagulable state.
 - Circulatory stasis.
 - Vascular wall injury.

Question 7

List the typical signs and symptoms related to PAD.

Answer 7

· Asymptomatic.
· Intermittent claudication - calf or foot cramping with walking that’s relieved by rest.
· Thigh or buttock pain with walking that’s relieved with rest.
· Diminished pulse.
· Sudden onset of severe leg pain accompanied by the 6 P’s.
· Erectile dysfunction.

Question 8

What are the 6 P’s?

Answer 8

1. Pain.
2. Paralysis.
3. Paraesthesias.
4. Pulselessness.
5. Perishingly cold.
6. Pallor.

Question 9

What investigations would you request if you suspected a patient had PAD?

Answer 9

· ABPI - <0.90. 
· Doppler. 
· Angiography. 
· CT angiogram. 
· Buergers - Arterial.
· Trendelenburg - Venous.

Question 10

Suggest some differentials.

Answer 10

· Spinal stenosis.
· Arthritis. 
· Venous claudication. 
· Chronic compartment syndrome. 
· Symptomatic Baker's cyst. 
· Nerve root compression.

Question 11

What treatment options are available for acute limb ischaemia?

Answer 11

· Urgent assessment:

• Revascularisation and intra-arterial thrombolysis (alteplase) - if viable limb.
• Amputation - is non-viable limb.

· Antiplatelet therapy - aspirin, clopidogrel.
· Analgesia.
· Anticoagulation - heparin.

Question 12

What treatment options are available for claudication?

Answer 12

· Antiplatelet therapy.
· Exercise.
· Risk factor modification.
· Revascularisation.

Question 13

Complications?

Answer 13

· Leg/Foot ulcers.
· Gangrene.
· Permanent limb weakness/numbness.
· Permanent limb pain.