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Aneurysms, ischaemic limb and occlusions
An aneurysm is a localised, permanent dilatation of an artery due to weakening of the vessel wall. 👉 Peripheral aneurysms (e.g., femoral, popliteal) often present as pulsatile masses and carry risks of thrombosis or rupture. Arterial occlusion can be acute (embolus, thrombosis) or chronic (atherosclerosis, peripheral arterial disease).
⚠️ Complications of Aneurysms
- 💥 Rupture: Life-threatening haemorrhage → shock.
- 🩸 Thrombosis: Intraluminal clot → acute limb ischaemia.
- 🚨 Embolization: Thrombus fragments lodge distally → “blue toe syndrome”, gangrene risk.
- 🧩 Compression: Adjacent nerves/veins → neuropathy, DVT, oedema.
🧑⚕️ Clinical Features
- 🔍 Pulsatile mass (e.g., femoral triangle, popliteal fossa).
- Groin/leg discomfort or swelling.
- Signs of acute limb ischaemia (“6 Ps”): Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishingly cold.
- Claudication in chronic occlusion.
🔎 Investigations
- 🩺 Bedside: Palpate pulses, ankle–brachial pressure index (ABPI).
- 🖥️ Duplex Doppler US: First-line for aneurysm size and flow.
- 🧲 CT/MR angiography: For operative planning.
- 🧪 Bloods: FBC, U&Es, coagulation screen (esp. pre-op).
🛠️ Management of Aneurysms
- 🆘 Emergency: Ruptured or acutely thrombosed → urgent vascular referral.
- 🔪 Surgical repair: Open resection & grafting for symptomatic, large (>2.5 cm femoral, >2 cm popliteal) or ruptured aneurysms.
- 🩻 Endovascular repair: Stent-graft in selected cases.
- 💊 Medical: Antiplatelets, statins, BP control for atherosclerotic disease.
🚨 Acute Limb Ischaemia (ALI)
ALI = sudden decrease in limb perfusion (<14 days), causing a threat to limb viability. Causes: embolus (AF, mural thrombus), thrombosis in situ (PAD), dissection, trauma.
- 🔑 6 Ps: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishingly cold.
- ❗ Paralysis and absent Doppler signals = late, poor prognosis.
- 💉 Immediate management: ABC, IV heparin bolus, urgent vascular surgery consult.
- 🔪 Definitive: Embolectomy, thrombectomy, bypass, or thrombolysis depending on cause.
🌙 Chronic Limb Ischaemia
- 🚶 Claudication: Pain on walking, relieved by rest.
- 🛌 Rest pain: Severe PAD, pain at night, relieved by hanging foot over bed.
- 🩻 Critical limb ischaemia: Rest pain + tissue loss/ulceration.
- 🛠️ Management: Risk factor modification (smoking cessation, statins, antiplatelets), supervised exercise, angioplasty, bypass if severe.
📌 Key Exam Pearls
- Always check bilateral femoral & popliteal pulses in suspected aneurysms.
- Acute limb ischaemia = surgical emergency → give heparin, call vascular urgently.
- Femoral aneurysms can mimic inguinal hernia or lymph nodes.
- Peripheral aneurysms are often multiple → check for popliteal/aortic aneurysm.
- Blue toe syndrome = cholesterol emboli from aneurysm or atheroma.
📚 References
- NICE CKS – Peripheral Arterial Disease
- Vascular Surgery Texts – Rutherford’s, Browse’s