Makindo Medical Notes

🚶‍♂️ Leriche Syndrome: buttock claudication + erectile impotence + absent femoral pulses ➝ due to aortoiliac occlusion (pudendal artery arises from internal iliac).

ℹ️ About

• 🦵 Intermittent claudication = exertional leg pain caused by anaerobic muscle metabolism due to reduced blood supply.

🩺 Causes

• Chronic atherosclerosis / arteriosclerosis (most common).
• Buerger’s disease (thromboangiitis obliterans).
• Arteritis (e.g. Takayasu’s disease).

⚡ Aetiology of Acute Ischaemia

• Thrombosis of an atherosclerotic artery.
• Embolism to a previously normal artery (often cardiac source: AF, mural thrombus, endocarditis).

📍 Common Sites

• 🩸 Aorto-iliac ➝ buttock/thigh/calf pain + impotence (Leriche syndrome).
• 🩸 Iliac-femoral ➝ thigh and/or calf pain.
• 🩸 Superficial femoral-popliteal ➝ calf pain only.

⚠️ Risk Factors

• Age, smoking, hypertension, hypercholesterolaemia, diabetes.
• History of MI, TIA, ischaemic stroke, or carotid disease.

🧾 Clinical Features

• Cramp-like pain in calves, thighs, or buttocks on exertion ➝ relieved by rest (hence “intermittent”).
• Causes limping ➝ “claudicare” = to limp.
• Represents peripheral vascular disease (PVD) in medium/large arteries.
• Progressive stenosis ➝ pain occurs earlier with exertion, eventually leading to rest pain.
• Signs: ischaemic ulcers, gangrene, shiny skin, hair loss, absent pulses.
• Often male, smoker, hypertensive, hypercholesterolaemic, diabetic.
• Frequently associated with systemic atherosclerosis (MI, stroke, carotid disease).

🌙 Rest Pain

• Pain at rest (especially in foot/ankle at night).
• Relieved by dangling leg off bed (gravity improves perfusion).
• Precedes ulceration and gangrene ➝ a marker of critical limb ischaemia.

🚨 Acute Ischaemia

• Classic “6 Ps”: Pain, Pallor, Pulselessness, Perishingly cold, Paraesthesia, Paralysis.
• Absent capillary refill and dusky mottling are late signs.

🧪 Investigations

• Bloods: FBC, U&E (CKD common), LFTs, ESR, lipids, glucose, HbA1c.
• 📉 ECG: may show old MI, AF, or LVH.
• 🧪 Elevated lactate in acute ischaemia.
• 🏃 Treadmill test ➝ measure functional claudication distance.
• 📏 Ankle–Brachial Pressure Index (ABPI): normal >0.9; claudication 0.4–0.9; rest pain/critical ischaemia <0.4.
• 🖼️ Imaging: Duplex/CT/MR angiography for treatable lesions.

💊 Management

• 📋 Best medical therapy: Aspirin (or clopidogrel), statin, strict smoking cessation, BP control, diabetes control, exercise programmes.
• 🩺 Endovascular ➝ angioplasty ± stenting (for focal disease).
• 🔧 Surgical ➝ bypass grafting (for extensive disease).
• 🚨 Acute ischaemia ➝ emergency revascularisation (embolectomy, thrombolysis, bypass) or amputation if unsalvageable.