24 Questions
Which of the following is the most common risk factor for peripheral arterial disease?
Smoking
What is the most common location in the leg for emboli?
Bifurcation of the common femoral artery
What is the characteristic of intermittent claudication?
Cramp-like pain, ache or tiredness brought on by exercise and relieved by rest
What is the primary indication for using POCUS in the diagnosis of emboli?
Features of thrombosis/emboli at aorta, iliac, femoral
What is the most common site of artery disease leading to limb ischemia?
Femoropopliteal
What is the term for the end of the spectrum of peripheral arterial disease, characterized by pain at rest, ulceration or gangrene?
Critical limb ischemia
Which of the following is a cause of embolism?
Aortic dissection
What is the significance of an ABI value of less than 0.9?
Chronic peripheral arterial disease
What is the percentage of upper limb acute limb ischemia cases due to thrombosis?
50%
What can occur following restoration of blood flow in acute limb ischemia?
All of the above
What is the most commonly affected artery in the upper limb for emboli?
Brachial artery
What is the significance of an ABI value greater than 1.3?
Non-compressible vessel
What is the most common cause of acute limb ischemia?
Thrombotic occlusion
What is the characteristic of acute limb ischemia?
Sudden decrease in blood supply to a limb
What is the purpose of checking for hypercoagulable state?
In patients under 50 years old with no known risk factor
What is the significance of Duplex USG in the diagnosis of peripheral arterial disease?
Determining ankle-brachial index
What is the gold standard for diagnosing ALI?
Invasive angiogram (digital subtraction angiogram)
What is the primary goal of anticoagulation therapy in ALI?
To reduce clot extension and recurrent embolization
What is an alternative to heparin in ALI treatment?
Lepirudin or argatroban
What is a complication of reperfusion in ALI?
All of the above
What is the recommended treatment for intermittent claudication?
Cilostazol
What is the definition of Rutherford Criteria?
A prognostic stratification of clinical stages of ALI
What is a definitive treatment for ALI?
All of the above
What is a possible complication of reperfusion in ALI?
All of the above
Study Notes
Acute Limb Ischemia (ALI)
- Definition: Sudden decrease in blood supply to a limb, leading to tissue hypoperfusion and threatening limb viability
- Causes:
- Embolism: less common, often from cardiac sources (e.g., atrial fibrillation)
- Thrombosis: majority of ALI cases, can occur in native vessels and bypass grafts
- Non-cardiac sources: aneurysms, atheromatous plaque, autoimmune disorders, etc.
Risk Factors for Peripheral Arterial Disease (PAD)
- Smoking and diabetes
- Additional risk factors: hyperlipidaemia, hypertension, elevated blood homocysteine, and elevated CRP
Clinical Features
- Intermittent claudication: cramp-like pain, ache, or tiredness brought on by exercise and relieved by rest
- Acute limb ischemia: pain over distal forefoot requiring the patient to hang their feet over the bed, suggestive of severe arterial occlusion
Diagnosis
- Imaging: POCUS, ECHO, Duplex USG, CTA contrast, MRI, and invasive angiogram
- Labs: cellular ischemia markers (CK, myoglobin, lactate), inflammatory markers (WCC, CRP, ESR), and hypercoagulable state screen
Rutherford Criteria (Prognostic Stratification of clinical stages of ALI)
- Classification of ALI into three categories: viable, threatened, and irreversible
Management
- Anticoagulation: IV unfractionated heparin or alternative anti-coagulants
- Definitive treatment: catheter-directed thrombolysis, percutaneous mechanical thrombolectomy, revision of an occluded bypass graft, and revascularization
- Treatment of intermittent claudication: cilostazol (phosphodiesterase inhibitor)
Complications
- Reperfusion Injury: metabolic derangement, compartment syndrome, rhabdomyolysis, arrhythmia, renal failure, and acute tubular necrosis
This quiz covers the approach and management of acute limb ischemia, including its definition, risk factors, and diagnosis. It also touches on critical limb ischemia and its relationship to peripheral arterial disease.
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