Week 21 - Arterial Ulcers, Gangrene, PVD, Varicose veins and venous ulcers

Question 1

what is Leriche Syndrome

Answer 1

occurs with occlusion in the distal aorta or proximal common iliac artery

Question 2

what is the clinical triad seen in Leriche Syndrome

Answer 2

thigh/buttock claudication
absent femoral pulses
male impotence

Question 3

what is Buerger’s test used to do

Answer 3

assess for peripheral arterial disease in the leg

Question 4

what are the two parts to Buerger’s test

Answer 4

The first part involves the patient lying on their back (supine). Lift the patient’s legs to an angle of 45 degrees at the hip. Hold them there for 1-2 minutes, looking for pallor. Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease. Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply. For example, a Buerger’s angle of 30 degrees means that the legs go pale when lifted to 30 degrees.

The second part involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour.

Question 5

in patients with peripheral artery disease, what colour will the legs go in the second part of the Buerger’s test

Answer 5

blue initially, as the ischaemic tissue deoxygenates the blood

dark red after a short time, due to vasodilation in response to the waste products of anaerobic respiration

Question 6

what is the dark red colour referred to as

Answer 6

rubor

Question 7

what do leg ulcers indicate

Answer 7

the skin and tissues are struggling to heal due to impaired blood flow

Question 8

what are arterial ulcers caused by

Answer 8

ischaemia secondary to an inadequate blood supply

Question 9

what are the typical characteristics of arterial ulcers

Answer 9

Are smaller than venous ulcers
Are deeper than venous ulcers
Have well defined borders
Have a “punched-out” appearance
Occur peripherally (e.g., on the toes)
Have reduced bleeding
Are painful

Question 10

what are venous ulcers caused by

Answer 10

impaired drainage and pooling of blood in the legs

Question 11

what are the characteristics of venous ulcers

Answer 11

Occur after a minor injury to the leg
Are larger than arterial ulcers
Are more superficial than arterial ulcers
Have irregular, gently sloping borders
Affect the gaiter area of the leg (from the mid-calf down to the ankle)
Are less painful than arterial ulcers
Occur with other signs of chronic venous insufficiency (e.g., haemosiderin staining and venous eczema)

Question 12

what are the investigations used in PAD

Answer 12

ABPI
Duplex ultrasound
angiography

Question 13

an ABPI above what can indicate calcification of the arteries

Answer 13

above 1.3 - making them difficult to compress
this is more common in diabetic patient s

Question 14

what are the medical treatments for management of intermittent claudication

Answer 14

atorvastatin 80mg
clopidogrel 75mg once daily
naftidrofuryl oxalate

Question 15

what is naftidrofuryl oxalate

Answer 15

5HT2 receptor antagonist that acts as a peripheral vasodilator

Question 16

what are the surgical treatment options for intermittent claudication

Answer 16

Endovascular angioplasty and stenting
Endarterectomy – cutting the vessel open and removing the atheromatous plaque
Bypass surgery – using a graft to bypass the blockage

Question 17

how is urgent revascularisation achieved in management of critical limb ischaemia

Answer 17

Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply

Question 18

what does gangrene refer to

Answer 18

the death of the tissue, specifically due to an inadequate blood supply

Question 19

what is it called when infections infect the gangrene

Answer 19

wet gangrene

Question 20

what is phantom limb pain treated with

Answer 20

gabapentin

Question 21

is oedema present in PVD

Answer 21

not commonly no

Question 22

what is a very poor prognostic sign in PVD

Answer 22

burning pain at night, due to elevation which reduces limb perfusion, and is relieved by hanging the legs over the side of the bed

Question 23

in what syndrome is erectile dysfunction seen in

Answer 23

Leriche syndrome

Question 24

what is the difference in pain between PVD and neurogenic claudication

Answer 24

pain starts in calf and typically radiates up the leg in PVD and in neurogenic claudication, pain typically starts in the buttock and radiates down the leg

Question 25

what should all patients with claudication be given

Answer 25

Statin (e.g. atorvastatin 40mg nocte) regardless of cholesterol levels
Control hypertension – for example an ACE-inhibitor (e.g. ramipril 5mg daily) or a calcium channel blocker (e.g. amlodipine 5mg daily)
β-blockers should be avoided, but are typically safe unless PAD is very severe
Antiplatelet agent – aspirin 100mg daily or clopidogrel 75mg daily – can improve claudication distance and reduce other symptoms.

Question 26

what are the indications for specialist referral in PVD

Answer 26

lifestyle limiting claudification

pain at rest

gangrene

Question 27

what is PTA

Answer 27

percutaneous transluminal angioplasty

useful for short lesions in big arteries

a balloon is used to widen the artery, which in some cases, may be enough on its own. in many cases, a stent is also placed

Question 28

what are varicose veins

Answer 28

Are tortuous dilated superficial veins
Are different to reticular veins or telangiectasia
Are caused by weak vein walls causing dilation and valve incompetence
Are often symptomless
Are investigated with Doppler venous scanning.
Can be left untreated, compressed, injected or operated on
Often recur

Question 29

what are the risk factors for varicose veins

Answer 29

↑Age
Pregnancy
↑ No. of pregnancies
Long periods of standing – e.g. occupation as a teacher, shop assistant, surgeon(!) etc
Family History

Question 30

to maintain adequate venous return against gravity, what are the two mechanisms put in place

Answer 30

the presence of valves, which prevent back-flow of blood distally

the deep venous system is assisted by pressures generated by muscles, noticeably the calf muscles

Question 31

what is thought to be the cause of varicose veins

Answer 31

weakness in the vein wall causes dilation of the vein

if it occurs around the valve, then the cusps of the valve will no longer meet in the middle and the valve will become incompetent, resulting in backflow of blood, and therefore inadequate drainage

Question 32

what are the most common valves involved in varicose vein formation

Answer 32

those around the saphenofemoral junction (in the groin), however they can occur in other places for example the junction between the short saphenous vein and the popliteal vein.

Question 33

what do secondary varicose veins result from

Answer 33

pelvis or abdominal mases, which obstruct blood from returning from the lower limbs

Question 34

what are the complications of varicose veins as a result of the veins themselves

Answer 34

bleeding
thrombophlebitis

Question 35

what are the complications of varicose veins as a result of venous hypertension

Answer 35

oedema
venous ulceration
pigmentation changes
lipodermatosclerosis
varicose exzema