2. DISCLAIMERS
• The following presentation is prepared by a medical student for
the sole purpose of peer-to-peer medical education.
• The content has not been reviewed or endorsed by a medical
practitioner or an educational body.
4. PERIPHERAL ARTERIAL
DISEASE - OVERVIEW
• Narrowing (stenosis or occlusion) of and
reduced blood flow to the peripheral
vasculatures
• Can affect any vessels in the lower limbs
• Mainly due to atherosclerosis
5. L O W E R
L I M B
A N A T O M Y
Source: Moore’s Anatomy
6. L O W E R
L I M B
A N A T O M Y
Source: Moore’s Anatomy
10. CLAUDICATION
• Claudication
• Cramping pain +/- paraesthesia
in the lower limbs
• Site of pain usually indicative site
of lesion (distal to lesion)
• Aorto-iliac hip/buttock
pain +/- sexual dysfunction
• Fem-pop calf pain
• Tib-fib foot claudication
• Worse on exertion, relieved with
rest
• Due to increased oxygen
demand
Source: https://www.bmj.com/content/bmj/suppl/2018/02/01/bmj.j5842.DC1/morr041877.wi.pdf
11. CLAUDICATION
• Claudication
• Cramping pain +/- paraesthesia
in the lower limbs
• Site of pain usually indicative site
of lesion (distal to lesion)
• Aorto-iliac hip/buttock pain
+/- sexual dysfunction
• Fem-pop calf pain
• tib-fib foot claudication
• Worse on exertion, relieved with
rest
• Due to increased oxygen
demand
Source: Bailey and Love’s Short Practice of Surgery
12. TROPHIC CHANGES
• Trophic Changes
• Relates to tissue loss or atrophy due to ischaemia
• Ulcers
• Gangrene/necrosis
• Shiny, hairless leg
• Pale legs
13. REST PAIN
• Rest Pain
• Sign of late-stage disease or critical limb ischaemia
• Pain worse with lying down
• Improved with feet hanging over the bed
14. DIAGNOSIS
• Ankle-Brachial Pressure Index (ABPI)
• Ratio of ankle SBP : brachial SBP
• Higher values calcification
• Lower values stenosis
• Alternative: Toe-Brachial Pressure
• Criteria:
• 0.9 – 1.2 : normal
• 0.4 – 0.9 : mild to moderate PAD
• < 0.4 : severe PAD
• >1.3 : calcification
15. DIAGNOSIS
• Duplex Ultrasound
• colour-coded duplex ultrasound
• Allows for localization of the site of stenosis and visualization
of turbulence and blood flow velocity
16. DIAGNOSIS
• Digital Subtraction
Angiography (DSA)
• Gold standard of diagnosis
• Injection of radio-opaque dye
• Images are digitalized –
background ‘noise’ digitally
removed –e.g. fats, bones, soft
tissue)
• Magnetic Resonance
Angiography (MRA) or
Computed Tomography
Angiography (CTA)
• Use of CT or MRI technology
19. CRITICAL LIMB
ISCHAEMIA
• Severe compromise of arterial flow to the
extremities due to chronic limb ischaemia
• Can be defined by 1 or more of:
• Ischaemic REST PAIN of > 2 weeks in
duration
• Ischaemic lesions – ulcers, gangrenes
• ABPI < 0.5
20. ACUTE LIMB
ISCHAEMIA
• Sudden decrease in limb perfusion
threatening the viability of the limb
• MEDICAL EMERGENCY!!
• Aetiology
• Thrombosis – PAD, stents/grafts
• Embolism – distal sources e.g. AF, post-MI,
cholesterol, aneurysms
• Trauma
• Others: vasoactive drugs, shock
