Etiology of peripheral arterial disease
Atherosclerosis
Differentials:
Beurger disease - thromboangiitis obliterans
vasculitis - takayasu arteritis, bechet disease
ergot toxicity
vasospasm
Cystic medial degeneration
Popliteal artery aneurysm - showering of emboli
Fibromyalgia dysplasia
Diagnostic criteria of critical limb ischemia
- rest pain req opioid analgesia
- tissue loss - ulcer, gangrene
- ABI<0.5, TPI<0.3, Toe pressure<30, Ankle pressure<50
for more than 2 weeks
Classification for acute limb ischemia
Rutherford classification I: viable II: threatened (a: marginally, image and revasc urgently b:immediately) - emergency revasc III: Irreversible, non viable - amputation
Sensory, motor, doppler - arterial and venous
Classification of chronic limb ischemia
Fontaine or Rutherford
0 - asymptomatic 1 - mild claud 2- mod claud 3- maj claud 4 - rest pain 5 - minor tissue loss 6 - major tissue loss (more than forefoot)
Investigations for PAD
Anatomical
- arterial duplex (us)
- CT angiogram
- lesser used: bone subtraction angiogram, MRA
Perfusion
- ABPI/ TBI
Management of PAD
Asymptomatic
- lifestyle
- manage various RF (smoking, HTN, DM - HbA1c)
- statins, single anti pat therapy
Claudicants, non debilitating
- supervised exercise therapy (30m, 3x/7, for 12w)
- drugs: naftidrofurul, cilostazol
Claudicants, debilitating; critical limb ischemia:
revascularisation (endoscopic angioplasty/ stenting, subintimal angioplasty vs bypass) - Transatlantic classification
Buerger’s test
significant if pallor when raised <20 deg
venous guttering
reactive hyperaemia when foot placed down from bed
What is a positive exercise test
fall of ABI >0.2 post exercise
When to repair AAA
Asymptomatic: threshold 5.5cm (follow up with u/s) - give statin to slow rate of growth
or >1cm/year or saccular aneurysm (rather than fusiform)
AND patient fit for surgery
Symptomatic: repair ASAP regardless of size - pain or distal embolisation
(optimise for surgery - CVS fx)
Criteria for AAA
Normal Aorta: 2-2.5cm
AAA: >3
Aortic diameter>50% than normal
<50%: ectasia
RF AAA
and
RF for rupture
smoking
male
family hx
disorders: marfan (fibrillin 1), Ehler danlos syndrome IV (type 3 collagen)
others: HTN, HLD, atherosclerosis, advanced age, hyperhomocysteinemia
RF for rupture:
COPD, smoking, larger initial AAA size, female gender, renal transplant, rate of enlargement
Types of rAAA presentation
- Classical: hypotension, shock, pain rad to back, pulsatile ab mass
- Local contained: radicular symptoms to thigh, groin with GI/urinary obstruction
- rupture into IVC (aortocaval fistula): audible ab bruit, venous HTN (swollen cyanotic legs, lower GI bleed, hematuria)
- distal embolisation (thrash foot)
Cx of AAA surgery
Intra-op: haemorrhage, distal embolisation (thrash), distal limb arterial thrombosis
Early: spinal cord ischemia (paralysis), ARF (oliguria), AMI, CVA, acute sigmoid colon ischemia, pneumonia, ARDS
Late: aortoenteric fistula, graft infection (Dacron graft), false aneurysm formation, sexual dysfunction, renal failure
Endovascular (EVAR) vs open AAA sx repair
Short term: endo mortality rate lower, and a/w lower aneurysm relate death
LT (4 y): endo has higher incidence of post op cx and need for re-intervention
endo needs long term follow up with CT angio to check position of stent
Position of SFJ
2.5cm inferolateral to pubic tubercle
How to confirm it is saphena varix
located at SFJ/ inguinal region, soft, compressible
collapsible when lying down, positive cough impulse
grading of chronic venous insufficiency
CEAP classification 0 - normal 1 - telangiectasia (<1mm), reticular veins (1-3mm) 2 - varicose veins (>3mm) 3 - edema 4 a venous eczema/ hyperpigmentation 4 b atrophie blanche, lipodermatosclerosis 5 - healed ulcer 6 - active venous ulcer
Venous ulcer management
first rule out marjolin cancer - biopsy
Conservative: 4 layer compression bandage
- first ensure ABI >0.8
1. non stick wound dressing + wool bandage
2. crepe bandage
3. blue line bandage (elset)
4. adhesive bandage (coban) - aim ankle pressure ~30mmhg
- also give: analgesia, antibiotics (if infx), avoid trauma, elevate legs when resting, compression stockings for life after healed
Surgical: split skin graft, venous sx for underlying pathology
Varicose veins management
- cx of surgery
Conservative:
- lifestyle: change job, avoid standing long durations
- daflon
- graduated compression stockings
Surgical if: 1. cosmesis, 2. symptomatic, 3. cx
- high tie with GSV stripping - stab avulsion (CI if DVT)
(cx: DVT , saphenous nerve injury) - US guided injection foam sclerotherapy
(cx: cutaneous necrosis, hyperpigmentation, telangiectasic matting, thrombophlebitis, allergic reaction, venous
thromboembolism) - endovenous laser/ radiotherapy saphenous vein ablation
(cx: skin burns, DVT, PE, vein perforation & hematoma, superficial thrombophlebitis)
Anatomical relations of GSV, SSV
GSV: passes anterior to medial malleolus, travel with saphenous nerve
SSV: passes posterior to posterior malleolus, travel with sural nerve
Special tests for venous PE
tourniquet test, trendelenburg test, perthes test, doppler ultrasound
arterial supply of LL
aorta > common iliac > int/ext iliac > common femoral
5 br: sup epigastric, sup circumflex art, sup ext pudendal art, deep ext pud art, profunda femoris (3 br: med/lat circumflex fem art, 4 perforating branches)
pop>ant/pos tibial, peroneal arteries
Description of dorsalis pedis
one third of the way down a line joining the midpoint of the two malleoli to the cleft between the first and second toe located between the extensor halluces longus and extensor digitorium longus
location of claudication vs site of dz
- buttock
- thigh
- calf
- foot
buttock/ impotence: stenosis of lower aorta/ common iliac (aortoiliac dz)
thigh: ext iliac, common fem, aortoiliac dz
calf: superficial femoral (femoral-popliteal dz)
foot: tibial peroneal dz
