Peripheral vascular disease

Question 1

What causes intermittant claudication? what are the clinical features?

Answer 1

This occurs when insufficient blood reaches exercising muscle.

The patient is pain-free at rest, but after variable periods of exercise develops ischaemic pain in the affected limb, which is relieved by further rest.

Question 2

How is peripheral vascular disease staged?

Answer 2

Fontaine stage:
I: normal
IIa: intermittant claud. >200m
IIb: intermittant claud. <200m
III: rest pain
IV: tissue loss

Question 3

what are the main risk factors for peripheral vascular disease? (6)

Answer 3

Male
Age
Diabetes
Smoking
HTN
Hypercholesterolaemia

Question 4

What are the pulses that you feel for in the leg?

Answer 4

• Femoral
• Popliteal
• Posterior tibial
• Dorsalis pedis

Question 5

What are the 2 non-invasive investigations for lower limb ischaemia?

Answer 5

Measurement of ABPI:
Ankle pressure/Brachial pressure (this is usually the same but as get worse, ankle pressure becomes alot lower than brachial)
-Duplex USS

Question 6

What is a normal/claudication/severe ABPI?

Answer 6

Normal: 0.8-1.2
Claudication: 0.4-0.85
Severe: 0-0.45

Question 7

What are the 3 invasive investigations for lower limb ischaemia?

Answer 7

Magnetic resonance angiography
CT angiography
Catheter angiography

Question 8

What are the important lifestyle factors to discuss with a patient who has lower limb ischaemia?

Answer 8

stop smoking (smoking is a risk factor for amputation)

importance of walking to develop collateral circulation and success of supervised exercise programmes

Question 9

What pharmacological management is involved in the treatment of lower limb ischaemia?

Answer 9

lipid lowering
antiplatelets
hypertension Rx
diabetes Rx (diabetes is a risk factor for amputation)

Question 10

What is the surgical management of lower limb ischaemia?

Answer 10

angioplasty
stent
bypass

Question 11

What are the 5 clinical features of critical limb ischaemia? What are these helped by?

Answer 11

Rest pain (lying/sleeping) = 
toe / foot ischaemia (nerve ending pain)

Ulcers/gangrene (trauma/footwear) = severe ischaemia and damage

Toes and forefoot

Requires strong analgesia

Worse at night

Helped by:

• sitting and putting the leg in a dependent position
• getting up and walking about

Question 12

What is the main management of intermittant claudication and critical limb ischaemia?

Answer 12

RISK REDUCTION

Question 13

What is acute limb ischaemia?

Answer 13

sudden loss blood supply to a limb:

-occlusion native artery or bypass graft

Question 14

what are 5 causes of sudden occlusion?

Answer 14

• Embolism
• Atheroembolism
• Arterial dissection
• Trauma
• Extrinsic compression

Question 15

What are the 6 P’s of acute limb ischaemia?

Answer 15

Pain 
Pallor 
Pulseless
Perishingly cold
Paraesthesia
Paralysis

Question 16

in acute limb ischaemia:

• describe pain
• what does a tight ‘woody’ compartment indicate?

Answer 16

Severe, sudden onset, resistant to analgesia

Calf/muscle tenderness with tight (‘woody’) compartment indicates muscle necrosis
Often irreversible ischaemia

Question 17

Describe the colour changes in the skin in acute limb ischaemia?

Answer 17

Limb initially white with empty veins

Later, capillaries fill with stagnated de-oxygenated blood giving a mottled appearance:
-Blanching mottling = salvageable if prompt revascularisation

Arteries distal to occlusion fill with propagated thrombus with rupture of capillaries
=Non blanching mottling = irreversible ischaemia

Question 18

Describe the clinical features seen:
0-4 hrs
4-12 hrs
>12 hrs

Answer 18

0-4hrs:
-white foot
-painful
-sensorimotor deficit
SALVAGEABLE

4-12hrs:
-mottled
-blanches on pressure
PARTLY REVERSABLE

>12hrs:
-fixed mottling
-non-blanching
-compartments red and tender
-paralysis
NON-SALVAGEABLE

Question 19

What is the management for acute limb ischaemia?

• bloods?
• Investigations?
• initial pharmacological mgt?

Answer 19

ABC – resuscitate and investigate

FBC, U/Es, CK, Coag +/- Troponin

ECG – MI, dysrhythmia

CXR – underlying malignancy

Anticoagulate:

• Stops propagation of thrombus
• May improve perfusion
• Regional vs General Anaesthesia

Question 20

When would you consider arterial imaging for acute limb ischaemia?

Answer 20

• No prior history of claudication
• Cause for embolism known
• Full complement of contra-lateral pulses

If doubts as to history: urgent CT angio/Catheter angio

Question 21

If limb is salvageable, what is the surgical management for acute limb ischaemia?

Answer 21

-Embolectomy
+/-
-fasciotomies
-thrombolysis

Question 22

If limb is not salvageable what is the management for acute limb ischaemia?

Answer 22

Palliation or amputation

Question 23

why is important to distinguish between acute vs acute on chronic acute limb ischaemia?

Answer 23

Different urgency and management

Importance of accurate history and exam

Question 24

What do diabetic foot problems encompass? what does this lead to?

Answer 24

Diabetic neuropathy
Peripheral vascular disease
Infection

Leads to tissue ulceration/necrosis/gangrene

May result in amputation

Question 25

What are the 3 different sources of diabetic foot sepsis?

Answer 25

simple puncture wound infection from the nail plate or inter-digital space from a neuro-ischaemic ulcer (occurs on areas of increased pressure, ie under the metatarsal heads).

Question 26

Why does the anatomy of the foot mean diabetic foot sepsis is a vascular surgical emergency?

Answer 26

Within the foot the intrinsic muscles of the digits are confined within rigid compartments bounded by plantar fascia, metatarsal bones and interosseous fascia. Infection tracks in the soft tissues into this rigid compartment if the build up of pus can't escape = pressure builds up in the compartments = ischaemia/further tissue damage =can rapidly progress to sepsis and ultimately limb loss (more of a pressure problem rather than an ischaemic problem)

Question 27

What are the clinical systemic signs 5 seen in diabetic foot sepsis?

Answer 27

``` Pyrexia Tachycardic Tachypnoeic Confused Kussmauls breathing ```

Question 28

What are the local signs seen in diabetic foot sepsis? 7

Answer 28

Swollen affected digit (‘sausage’ like) Swollen forefoot (‘boggy’ feeling to swelling) Tenderness Ulcer with pus extruding Erythema, may track up the limb Patches of rapidly developing necrosis Crepitus in the soft tissues of the foot (Gas from gas forming organisms) (may or may not feel pedal pulses)

Question 29

what organisms can cause diabetic foot infection?

Answer 29

Gram +ve cocci (S. aureus + Streptococcus sp.) Gram –ve bacilli (E. coli, Klebsiella sp, Enterobacter, Proteus sp and Pseuodomonas sp.) Anaerobes (Bacteroides)

Question 30

What is the management of diabetic foot sepsis?

Answer 30

Abiotics Rapid surgical debridement of infected tissue If performed at early stages the foot and limb may be salvaged Remove all infected tissue Wound open to encourage drainage