Rutherford classification
A viable limb consists of these physical exam findings
What are normal sensory and motor exams and audible Doppler signals?
Even though there has been an acute reduction in blood supply to the limb, it is either very early on in the time course of the ischaemia, or the overall perfusion of the limb is enough to maintain its viability
This is helpful for hearing pulses at bedside.
Doppler
Name 3 modifiable risk factors of PAD
smoking, HTN, HLD, DM, CKD, Obesity
24-year-old man presents to the emergency department reporting numbness and tingling in his left hand and severe pain and swelling in his left forearm for the past hour. He says that he was repeatedly injecting heroin into his arm earlier in the day. Upon physical exam, his hand is pale, cool to the touch, and there is severe pain on passive movement of the fingers. His radial and ulnar arteries have monophasic flow on hand-held Doppler. The next best step is:
What is a fasciotomy?
Compartment syndrome can develop from injection into a compartment. The injected material and the edema that follows cause increased pressure. Multiple injections into a compartment space can cause a reaction that increases pressure enough to produce symptoms quickly and can lead to the risk of limb loss if there is not immediate fasciotomy and debridement.
Acute limb ischemia is defined by disruption of blood flow with symptoms lasting for this time period.
What is less than two weeks?
A patient complaining of sensory disturbance in the toes, forefoot, fingers, or hand is without motor deficit characteristic of this stage.
What is type IIa?
Name 3 physical exam findings of acute limb ischemia.
(Hint: pick a letter)
pain, pallor, pulselessness, perishing cold, paresthesia, and paralysis
This group has the highest prevalence of PAD.
Black ethnicities
A 53 yo pt with 1 ppd 40 year smoking history and no other associated morbidities presents to the clinic with complaints of some intermittent claudication and can complete the exercise test. This patient can be managed ______.
conservatively
smoking cessation and exercise
Name the 3 levels of lower extremity amputation
above the knee, at the knee, below the knee
Stage IIa is considered _________ threatened. Stage IIb is considered ________ threatened.
What is marginally and immediately?
ABI less than this value often classifies chronic limb ischemia
< 0.4
This medication class has been shown to reduce all cause and cardiovascular related mortality.
antiplatelet therapy
ASA, plavix (clopidogrel), eliquis (apixaban), brillinta (ticagrelor)
84-year-old man with HTN, DM2, and COPD is brought to the ED by his caregiver because dry, necrotic first and second distal toes on his right foot (image below) and has failed to heal with conservative management by his primary care doctor. This is the next best step.
ABI
Noninvasive vascular laboratory studies such as ankle-brachial or toe-brachial indices (ABI or TBI), segmental Doppler pressure measurements, pulse volume recordings, and duplex ultrasonography are all helpful in distinguishing ischemic rest pain from other causes of limb pain
Name 3 medications used for conservative management of chronic limb ischemia.
Statins, antiplatelet drugs, antihypertensives
Arterial signals falling from audible to inaudible in a patient with some sensory deficit progressing more proximally and progressing motor weakness has progressed from this stage to this stage.
What is 1a to 1b?
WiFi stratifies limb risk by evaluating these 3 factors.
Wound
Ischemia
Foot infection
What are bypass grafts or endovascular stent grafts?
55 yo M with extensive smoking history presents to ED with cold toes and absent pedal pulses. IV heparin is started. Several hours later, audible doppler pulses return on physical examination. However, prior to further intervention, pulses once again become absent. Name the causes and intervention.
revascularization and swelling and fasciotomy
bonus how many compartments would you release?
A ______ embolectomy balloon catheter is passed proximal and distal to retrieve thrombus
What is Fogarty?
Name 3 findings of stage 3 limb ischemia.
Insensate.
Paralysed.
Rigid, painful muscle bellies.
Fixed tissue staining.
No arterial or venous Doppler signals audible.
The 6 P's present & limited to toes with strong pedal pulses. These physical exam findings suggest this etiology.
Artheroemboli
aka blue toe syndrome
may also present with scatter petechiae and plantar cyanosis
This event is a common preface to common femoral artery bifurcation emboli
Also AFib
A 68-year-old man presents to the ED with a 4-hour history of bilateral lower extremity pain and lower extremity weakness. The patient's legs are cold and pale, there are no palpable femoral pulses, and there is decreased sensation over both lower extremities. Until today, the patient was ambulatory and gave no history of claudication. ECG suggests a previous MI, and the patient appears to be in atrial fibrillation. Name 3 next steps in management.
IV heparin
CTA
Thromboembolectomy
Bonus: consider fasciotomy
Name 3 classifications for chronic limb ischemia
Fontaine - for research
Rutherford - based on symptoms
TASC II - transatlantic consensus document