Vascular Disease in the Lower Limb

interventional radiology

• use of imaging techniques to affect treatment rather than just for diagnosis

  • minimally invasive alternative to surgery

  • allows new therapeutic options

  • possible when there is no other option

duplex scanning

• no ionising radiation

• readily available

• velocity measurements

• operator dependant

CT angiography

• readily available

• assessment of aortic aneurysms

• assessment of bleeding

• assessment of peripheral vessels

MR angiography (MRA)

• non invasive

• no ionising radiation

• disadvantages

  • availability

  • overestimates stenoses

  • unsuitable for all patients→ claustrophobia, pacemakers

contrast angiography

• ‘gold’ standard

• comprehensive

• disadvantages

  • invasive→ complications

    • procedure related

    • contrast related

access to the arterial tree

• superficial artery

• readily compressible e.g. overlying bony structure

ABPI (ankle brachial pressure index)

• ankle systolic BP: brachial systolic BP

• normal: 0.8-1.0

abnormal ABPI

• moderate disease→ 0.5-0.8

• severe disease→ 0.3-0.5

• critical ischaemia→ <0.3

• can be elevated 1.2-1.4 in calcified vessels

clinical features of ischaemia

• pain

• paralysis

• paraesthesia

• pallor

• pulselessness

• perishingly cold

classification of acute limb ischaemia

I. Viable

IIa. Marginally threatened

IIb. immediately threatened

III. irreversible injury

I. Viable

• not immediately threatened

• no sensory loss

• no muscle weakness

• doppler sign present

IIa. Marginally threatened

• salveagable

• minimal (toes) or no sensory loss

• no muscle weakness

• often inaudible doppler sign

IIb. Immediately threatened

• salvageable with immediate revascularisation

• sensory loss in more than toes, pain

• mild to moderate muscle weakness

• usually inaudible doppler sign

III irreversible injury

• major tissue loss or permanent nerve damage

• profound sensory loss, anaesthesia

• paralysis

• arterial and venous inaudible doppler sign

treatment options for acute ischaemia

• endovascular

  • thrombolysis

  • aspiration/mechanical thrombectomy

  • angioplasty + stenting

• surgical

  • surgical thrombectomy/embolectomy

  • bypass