Vascular 2

Question 1

what classificatin system is used for peripheral arterial disease

Answer 1

Fontaine classification

Question 2

Describe the fontaine classification system

Answer 2

• Stage 1: Asymptomatic
• Stage 2: IC
• Stage 3: Rest pain
• Stage 4: Ulceration/ gangrene

Question 3

How do you do a peripheral arterial examination

Answer 3

• Introduce yourself
• ask if they have any pain
• are you comfortable
• look at the room
• expose your patient from the umbillicus to the toes - but being in an exam you wont
• make sure the legs are down on the couch
• say what you can see
• say something about the symmetry of the legs - swelling? dressings? scars? hair distribution changes? discolouration? muscle wasting(inner aspect of thighs the muscle will be thinner)?dryness? ulcers?
• look at the nails and how the quality of the nails are - brittleness is a sign of peripheral vascular disease
• start with temperature - cool legs are associated with more vascular problems
• run the back of the hands all the way down
• sometimes the leg can be hotter than normal
• do the capillary refill - press on the end of the halux and for 5 seocnds - let go after the 5 seconds and watch how long it takes for the colour to return - need it to return within 2 seconds
• then examine the pulses - abdominal aortic aneurysm- lie the patient down and touch on the tummy and press on it - tell them that it will be uncomfortable
• look for a pulsation in 3 directions
• femoral pulses in the groin
• popliteal artery - relax the hamstring muscles
• dorsal pedis pulse
• posterior tibial pulse – do them at the same time
• if they have vein issue they are best assessed standing up

Question 4

What is acute ischaemic limb

Answer 4

• Rest pain for less than two weeks requiring analgesia • And/or ulceration
• And/or gangrene
• Ankle pressure < 50mmHg
• Toe pressure ( in diabetics ) < 30 mmHg

Question 5

What are the causes for acute ischaemia limb

Answer 5

Thrombosis (60%) acute on chronic
• Atherosclerosis
• Popliteal aneurysm
• Graft occlusion
• Thrombotic conditions (PRV)

Embolism (30%) acute
• AF (80%)
• Mural thrombosis
• Vegetations
• Proximal aneurysms and plaques

Question 6

what are the 6ps that you should check in acute ischaemia limb

Answer 6

• Pain
• Pallor
• Perishingly cold
• Pulseless
• Paraesthesia
• Paralysis

Question 7

describe the progression of acute ischaemia in the limb

Answer 7

0-6 hrs: Marble white leg
• Intense vasospasm of distal arterial tree
• Emptying of veins

6-12 hrs: Mottled leg
• Vasodilatation in response to smooth muscle hypoxia
• Fills with deoxygenated blood
• Still blanches

12 hrs +:Irreversible ischemia
• Stagnant blood coagulates and thrombus propagates
• Capillary rupture causing fixed staining
• Tense muscles
• Blistering

Question 8

How do you classify actue limb ischaemia

Answer 8

Category 1

• not immediately threatened
• no sensory loss
• no muscle wekaness
• audible arterial doppler
• audible venous doppler

Category IIa

• salvable if prompt treatment
• minimal sensory loss in the toes
• no muscle weakness
• inaudible arterial droppler
• audible venous doppler

Category IIb

• Salvable if immediate treatment
• moderate sensory loss plus pain
• mild/moderate muscle weakness
• inaudible arterial doppler
• audible venous doppler

Category III

• major tissue loss or permanent nerve damagae inevitable
• profound sensory loss or anaesthetic
• profound muscle weakness/paralysis
• inaudible arterial doppler
• inaudible venous doppler

Question 9

in Acute limb ischaemia describe the differences between a viable leg, threatened leg and irreversible

Answer 9

Subcritical: Viable leg
• Reduced capillary refill
• No neurological deficit
• Audible arterial HHD signal

Critical acute ischaemia: Threatened leg
• Partial neurological deficit
• Inaudible signals on HHD

Irreversible acute ischaemia:
• Absent capillary refill
• Complete neurological deficit
• Tense muscles
• No doppler signal

Question 10

What investigations do you carry out for acute limb ischaemia

Answer 10

• Blood
• ECG
• CXR
• Echo
• Imaging of arterial tree