Peripheral Arterial Disease (PAD)

Question 1

Provide a definition of Peripheral Arterial Disease (PAD)

Answer 1

• common condition
• build up of fatty deposits in the arteries restricts blood supply to the leg muscles
• aka peripheral vascular disease

Question 2

What are the symptoms of PAD?

Answer 2

• many people have no symptoms (although they may have signs)
• painful ache in legs when walking, usually disappears after a few minutes’ rest (intermittent claudication)
• pain can range from mild to severe
• both legs are often affected at the same time; pain may be worse in one leg

Question 3

What are the signs and symptoms of PAD?

Answer 3

• hair loss on the legs/feet
• cyanosis
• dependent rubor
• numbness or weakness in the legs
• brittle, slow growing toe nails
• ulcers (open sores) on the feet/legs which don’t heal
• changes in skin colour on the legs e.g. pale or blue
• shiny skin
• in men, erectile dysfunction
• muscles in legs wasting
• diminished or absent pulses
• unremitting pain at night relieved by dangling foot out of bed or standing on a cold floor

Question 4

What do you need to be aware of concerning PAD?

Answer 4

• symptoms of PAD often develop slowly, over time
• if symptoms develop quickly or suddenly worsen it could be a sign of a serious problem requiring immediate treatment

Question 5

What are the risk factors for PAD?

Answer 5

• atherosclerosis
• smoking - most significant risk factor
• type 1 & 2 diabetes
• high blood pressure
• high cholesterol
• old age
• family history
• alcohol
• poor diet
• sedentary lifestyle
• obesity
• poor sleep
• stress

Question 6

When should you refer?

Answer 6

• all patients should see GP if they experience recurring leg pain when exercising (may be mistaken for growing older, but not reason why an otherwise healthy person should experience leg pain)
• PAD is usually diagnosed through a physical examination by the GP + ankle brachial pressure index (ABPI)
• difference between ankle/brachial blood pressure may indicated PAD

Question 7

Although PAD isn’t immediately life-threatening, the process of atherosclerosis that causes it can lead to which serious and potentially fatal problems?

Answer 7

• PAD makes you more likely to develop another form of CVD
• coronary heart disease
• stroke
• heart attack
• angina

Question 8

What is critical limb ischaemia (CLI)?

Answer 8

• blood flow to legs becomes severely restricted
• CLI is an extremely serious complication and requires immediate referral
• end stage of PAD: inadequate blood supply to limb; results in non-healing ulcers and gangrene

Question 9

What are the symptoms of CLI?

Answer 9

• severe burning pain in the legs and feet that is continuous when resting
• skin turning pale, shiny, smooth and dry
• loss of muscle mass in the legs
• the skin on the toes or lower limbs becoming cold and numb, turning red and then black and/or beginning to swell and produce foul-smelling pus, causing severe pain (gangrene)
• wounds and ulcers (open sores) on feet and legs that don’t heal

Question 10

What physical examination should you perform for PAD?

Answer 10

• physically examine the legs
• shiny skin
• brittle toe nails
• hair loss on the legs and feet
• pulse in the leg being very weak or undetectable
• leg ulcers
• reduced skin temperature/temperature differences between legs
• reduced sensation
• prolonged capillary refill time > 2 secs
• muscle atrophy
• femoral, popliteal and foot pulses
• CVS exam - BP, heart sounds

Question 11

What test is widely used to diagnose PAD?

Answer 11

• ankle brachial pressure index (ABPI)

Question 12

How is the ABPI (ankle brachial pressure index) measuring?

Answer 12

• blood pressure in the upper arms and ankles

Question 13

How are measurements for ABPI (ankle brachial pressure index) read?

Answer 13

• measurements taken with Doppler probe - uses sound waves to determine blood flow in the arteries
• second result (ankle) / first result (arm)
• if results < 1, then potentially PAD

Question 14

What does the result of the ABPI (ankle brachial pressure index) mean?

Answer 14

• if ABPI = 1, then blood pressure in both parts of body are the same, or almost the same
• if blood pressure in ankle is lower due to reduced blood supply, ABPI would be < 1 e.g. 0.8 and below is concerning)

Question 15

What is the equation for measuring ABPI (ankle brachial blood pressure)?

Answer 15

ABPI (leg) =

P Leg (highest systolic pressure in leg of either dorsalis pedis or posterior tibial arteries)

—————————————————————————————

P Arm (highest systolic pressure in arm of either left/right arm brachial systolic pressure)

Question 16

What other testing is available for PAD

Answer 16

• ultrasound scan
• angiogram
• contrast agent may be injected directly into the arteries of the leg and x-rays may be used to produce the images

Question 17

What treatments are available for PAD?

Answer 17

• lifestyle changes and medication
• exercising regularly
• stopping smoking
• eat a healthy diet
• lose weight if you’re overweight/obese
• moderate alcohol

Question 18

What referral options are available for patients?

Answer 18

• revascularisation surgery - pain in leg severe and prevents patient from carrying out every day activities or if symptoms fail to change with lifestyle changes
• 2 main types: angioplasty or artery bypass graft

Question 19

How would you differential diagnoses between mechanical leg pain that stops the patient from walking and PAD?

Answer 19

• mechanical pain more likely to be aggravated with movement and persists through rest for short period of time
• PAD would be aggravated by movement, but be alleviated by short rests
• patient case Hx indicating family history of CVS or personal history of CVS
• patient is a smoker, overweight, poor nutrition
• patient’s skin would be hairless, shiny, colour (blue/pale), calmly/sweaty in PAD, none of these would be evident if MSK
• if male ask about erectile dysfunction might indicate PAD
• bilateral muscle wastage/numbness/tingling might indicate PAD
• brittle nails, ulcers on legs and feet which don’t heal may indicate PAD

Question 20

What are the more serious consequences of PAD?

Answer 20

• stroke
• CAD
• myocardial infarction
• angina

Question 21

Your patient tells you they have been diagnoses with PAD and they have come to you for some advice … what might you suggest?

Answer 21

• reduce alcohol consumption
• gentle physical activity
• stop smoking, if smoker
• lose weight if overweight
• eat healthy diet

Question 22

What are the 6 Ps for critical limb ischemia?

Answer 22

• pain
• pallor
• pulseless
• paresthesia
• perishing cold

Question 23

What are the red flags of critical limb ischaemia?

Answer 23

• extertional discomfort - most common in calf - relieved by rest

Question 24

What are the medical co-morbidities of PAD?

Answer 24

• diabetes
• hypercholeseterolemia
• hypertension
• chronic kidney disease
• inflammatory conditions e.g. rheumatoid arthritis
• atypical antipsychotic medications

Question 25

What advise and patient education can you provide for PAD?

Answer 25

- lifestyle support and advice - smoking, alcohol, diet - optimise medical treatment of comorbidities e.g. diabetes - exercise - anti platelet drugs

Question 26

What tests/examinations are available for referral off CLl?

Answer 26

- contrast MRI - medications e.g. atorvastatin, clopidogrel, naftidrofuryloxalate

Question 27

What differential diagnosis is there for acute limb ischaemia (acute limb ischemia - commonly miss diagnosed and not considered)?

Answer 27

- chronic peripheral neuropathy e.g. diabetic neuropathy => pulses present, unless chronic arterial occlusive disease/vasospasm + skin temp normal - acute compressive peripheral neuropathy e.g. compartment syndrome = tense muscle compartments (not present in acute limb ischaemia) - acute DVT = pulses usually palpable, oedema does not usually occur with acute limb ischaemia

Question 28

Give some differential diagnosis of intermittent claudication

Answer 28

- nerve root compression - sharp, lancinating pain, radiating down the leg, exacerbated by sitting, standing, walking and improved by change in position - hip arthritis - aching discomfort in lateral hip and thigh after exercise, not quickly relieved, may improve with not weight bearing - spinal stenosis - often bilateral pain and weakness affecting buttocks and posterior leg. Worse on standing, relieved by flexing the lumbar spine - foot + ankle arthritis - aching pain in ankle and foot arch. Influenced by activity, doesn’t resolve quickly, may be relieved by not weight-bearing - less common compartment syndrome, venous claudication and symptomatic Baker’s cyst

Question 29

Chronic limb-threatening ischaemia can be missed if symptoms are confused with which other foot pain causes?

Answer 29

- plantar fasciitis - cellulitis - gout - arthritis

Question 30

Give some differential diagnosis of claudication

Answer 30

- arthritis - chronic compartment syndrome - muscle strain - baker’s cyst - nerve entrapment - nerve root compression - spinal stenosis - DVT - Vasculitis