• Buerger’s angle:
  • Patient lies flat on couch
  • Check for hip pain
  • Slowly flex the hip, keeping the leg straight
  • Note if the leg turns white and if so, at what angle? This is Buerger’s angle
  • People with a healthy peripheral vasculature don’t have a Buerger’s angle
  • The lower Buerger’s angle, the more severe the peripheral arterial disease; a Buerger’s angle of 20 degrees or less indicates severe peripheral arterial disease
• Buerger’s test:
  • After finding Buerger’s angle, ask the patient to sit up and swing their legs over the side of the bed
  • Buerger’s test is positive if the leg turns purple, red and painful (reactive hyperaemia – also known as the Tequila sunset sign)

• Using a Doppler probe
• Measure systolic BP in both arms (inflate cuff until pulse disappears and note cuff pressure)
• Measure systolic BP in dorsalis pedis and posterior tibial arteries of one leg (same technique as above)
• The highest ankle pressure divided by the highest brachial pressure equals the ABPI
• 

• > 1.3 = calcified vessels e.g. diabetes
• 9-1.2 = normal
• 8-0.9 = mild peripheral arterial disease
• 5-0.8 = moderate peripheral arterial disease. Compression bandages for venous disease are contraindicated.
• <0.5 = critical limb ischaemia

• Diabetes mellitus
• Hypertension
• Hyperlipidaemia
• Family history
• Tobacco Smoking

• Acutely
  • Acute limb ischaemia
  • Acute-on-chronic limb ischaemia
• Chronic
  • Asymptomatic
  • Intermittent claudication
  • Critical limb ischaemia
• Incidentally
  • With associated coronary artery disease
  • With associated cerebral vascular disease

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

• Thrombosis (70%)
• Emboli (25%)
  • AF
  • Post-MI
  • Prosthetic metallic valves, bypass grafts
  • Aneurysmal
  • Paradoxical embolus (DVT through ASD)
• Other causes:
  • Trauma
  • Aortic dissection
  • Iatrogenic injury
  • Compartment syndrome
  • Extreme cold
  • Raynaud’s

• Six hours or less. After this window limb viability drops off rapidly.

• Thrombotic cause:
  • Urgent CT angiography plus balloon angioplasty/ open surgery
• Embolic causes
  • Catheter directed thrombolysis plus post- interventional anticoagulation with LMWH
  • Surgical arterial embolectomy plus post-op anticoagulation with LMWH
• Unsalvageable limb: primary amputation

• Compartment syndrome
  • May perform prophylactic fasciotomy at time of revascularisation to prevent this
• Rhabdomyolysis
  • Myoglobinuria
  • Acute kidney injury
  • Hyperkalaemia, metabolic acidosis
• Cardiac stunning
• Non-cardiogenic pulmonary oedema, ARDS

• Cramping calf/thigh/ buttock pain felt after walking for a given distance (the claudication distance) and relieved by rest
• Calf claudication suggests femoral disease
• Buttock pain suggests iliac disease.

Conservative

• Education
• Supervised exercise programme
• Secondary prevention
  • Healthy diet
  • Regular exercise
  • Weight loss
  • Smoking cessation
  • Aspirin 75mg OD
  • Statin (e.g. atorvastatin 40-80mg ON)
  • HTN treatment
• Medical
  • Vasodilators (e.g. naftidrofuryl oxalate and cilostazol)
• Interventional radiology
  • Balloon angioplasty
• Surgical
  • Bypass grafting
  • Amputation

• Pain at rest associated with the requirement for strong analgesia for at least 2 weeks/ tissue necrosis or gangrene
• and ABPI <0.5
• The above indicate end-stage chronic peripheral arterial disease

• Burning pain at rest
• Nocturnal pain that wakes patient from sleep
• Pain may be relieved by hanging limb over side of bed/ walking on cold floor

• • ABC approach
  • Analgesia
    • WHO pain ladder, PRN antiemetic and laxative
    • TCA or gabapentin may be used early
    • Consider referral to pain management team
  • Refer to MDT
  • Urgent CT angiography for treatment planning:
    • Conservative (as for intermittent claudication)
    • Interventional radiology
      • Urgent balloon angioplasty
    • Surgery
      • Urgent bypass surgery
      • Amputation