WEEK 27- CASE 2CHILAN NGUYEN

PATIENT PRESENTATION

Mr Doug McCutcheon 69 y.o male Recently moved into self-care

units at local Aged Care Facility that you look after

Worsening pain in legs Unable to walk up the hill to

bus stop because of pain in his calves

Previously had been enjoying daily walks

DIFFERENTIAL DIAGNOSIS OF LOWER LEG PAIN

• Peripheral arterial disease • Vascular insufficiency• Vasculitis• Deep venous thrombosis

• Spinal stenosis• Nerve root compression (e.g herniated disc)• Peripheral neuropathy (diabetes mellitus, alcohol

abuse)• Nerve entrapment• Arthritis• Symptomatic Baker’s cyst• Muscle strain• Ligament/tendon injury• Chronic compartment syndrome

Vascular

Neurological

Musculoskeletal

FURTHER HISTORY

Bilateral calf pain. R>L Discomfort has progressively worsened over the past 6

months Now has to rest after walking half a block uphill at regular

pace or after 5 min on level ground Tight, cramp like Severe, unable to continue walking Disappears after 1-2 minute rest

Pain wakes him up at night- improves if he dangles his leg over the bed

FURTHER HISTORY

No changes in sensationNo leg/feet ulcersNo any discolouration of

the feetNo pain with active

movement LL or prolonged sitting

No leg swelling

No back painNo bladder/bowel

dysfunctionNo history of recent

acute injury/traumaNo recent extended

travelNo fevers, night sweats,

anorexia

FURTHER HISTORYPMHx Previous TIA Hypertension Hyperlipidaemia Overweight T2DMMEDICATIONS Perindopril Atorvastatin AspirinALLERGIES: NKA

SHx Retired postal worker Widower- wife died 10 years ago

from breast cancer 3 children, 6 grandchildren- in

contact and in good health Independent mobility w/o aids Independent ADLs Plays lawn bowels 2 x week No ETOH Smokers- 50 pack year.

FURTHER HISTORY

FHxMother- passed away from

stroke in her 80’ssFather- passed away from AMI in

his 70’sBrother- has had a “mini stroke”

PHYSICAL EXAMINATION

GENERAL Overweight; BMI: 28 No distress or resting painVITALS BP: 145/95 HR: 82, strong, regular SpO2: 97% on RA RR: 19bom Temp: afebrile

PHYSICAL EXAMINATION- LOWER LIMB EXAMINATION

OBSERVATION Colour: Slightly pale feet Skin- thin, shiny, loss of

hair to toes Nails- brittle, hypertrophic

and ridged No ulcerations or

gangrene No soft tissues swelling

PHYSICAL EXAMINATION- LOWER LIMB EXAMINATIONPALPATION Temperature: slightly cool to touch Capillary refill: R-5sec, L-4sec Peripheral pulses

Femoral- present bilaterally Popliteal- present bilaterally Dorsalis pedis- absent in ®, reduced

on (L) Posterior tibial- reduced on the ® +

(L)ABDOMEN: abdominal aorta not pulsatile or expansileNo lympadenopathy

AUSCULTATION No bruit heard over the femoral artery

bilaterally

NEUROLOGY EXAMINATION No sensory loss No gross motor loss SLR- NAD

BUERGER’S SIGN Bueger’s angle: ® 60 degrees

(normal > 90) Turns purple-red after lowering

PLEASE ANSWER SHORT ANSWER QUESTION 1 AND 2

ANKLE BRACHIAL INDEX

Ankle-brachial index (ABI)= Higher of SBP of each arm________higher ankle SBP (tib post or dorsalis pedis)

Interpretation Normal: 0.90-1.30 Intermittent claudication:

0.40-0.90 Chronic limb ischaemia <o.40

BEDSIDE INVESTIGATIONSANKLE: BRACHIAL INDEX Left: 0.80 Right: 0.50

INTERPRET??

SEGMENTAL PRESSURE EXAMINATIONS:: to help identify location of arterial stenosis

Measure SBP at the upper thigh, lower thigh, upper calf, lower calf

Difference of >20mmHg between 2 adj sites Stenosis in between

Exercise treadmill test with ABI: for atypical exertional leg pain or ulcer Abnormal if ABI falls by <20% post

exercise

DIFFERENTIAL DIAGNOSIS OF LOWER LEG PAIN

• Peripheral arterial disease • Venous insufficiency (no swelling)• Vasculitis (no other systemic symptoms)• Deep venous thrombosis (no swelling, tenderness)

• Spinal stenosis• Nerve root compression (e.g herniated disc)• Peripheral neuropathy (diabetes mellitus, alcohol

abuse)• Nerve entrapment• Arthritis• Symptomatic Baker’s cyst• Muscle strain• Ligament/tendon injury• Chronic compartment syndrome

Vascular

Neurological

Musculoskeletal

ARTERIAL Neurogenic VENOUS

PATHOLOGY Lumbar nerve roots or cauda equine compression (spinal stenosis)

Obstruction of venous outflow

SITE OF PAIN

Ill-defined, whole leg. Shooting, with ass. Tinging, numbness

Whole leg-bursting

LATERALITY Femoral-popliteal disease: unilateralAorto-iliac disease: bilateral

Often bilateral

ONSET Exercise induced. Gradual onset

Often immediate upon walking Gradual onset. With stasis

RELIEVING FEATURES

Gradually subsidesWith stopping of walking

COLOUR Normal/pale Cyanosed

TEMPERATURE Normal

SWELLING Absent

PULSES Present but may be difficult to feel 2oswelling

STRAIGHT LEG RAISE

Normal

ARTERIAL Neurogenic VENOUS

PATHOLOGY Occlusion/Stenosis of arteries Lumbar nerve roots or cauda equine compression (spinal stenosis)

Obstruction of venous outflow

SITE OF PAIN

Calf, thigh, buttocks Ill-defined, whole leg. Shooting, with ass. Tinging, numbness

Whole leg-bursting

LATERALITY Femoral-popliteal disease: unilateralAorto-iliac disease: bilateral

Often bilateral unilateral

ONSET Exercise induced. Gradual onset

Often immediate upon walking Gradual onset. With stasis

RELIEVING FEATURES

Quickly residesRest or dependent positioning

Gradually subsidesWith stopping of walking

Leg elevation

COLOUR Normal/pale normal Cyanosed

TEMPERATURE Normal/cool Normal Normal/ increased

SWELLING Absent Absent Always present

PULSES Reduced or absent Normal Present but may be difficult to feel 2oswelling

STRAIGHT LEG RAISE

Normal Limited Normal

LOWER LIMB ARTERIES ANATOMY

Aorta common iliac artery external iliac artery Common femoral artery Profunda femoris or Continues as superficial femoral artery

popliteal artery Anterior tibial artery dorsalis pedis Tiboperoneal trunk

fibular artery or Posterior tibial medial and lateral plantar arteries

PATHOPHYSIOLOGY OF CLAUDICATION PAIN

Arterial insufficiency, most commonly due to atherosclerotic narrowing/occlusion of LL arteries causes ischaemic muscle pain on walking At rest: blood/O2requirements are

met by collateral circulation through profunda femoris

With exercise: O2 demand increases but cannot be met ischaemia lactic acid accumulation, low pH , ATP release by damage cells pain

What are the risk factors for peripheral artery disease??

MCQ QUESTION

Which of the following are all risk factors for peripheral artery disease?a) Hyperlipidadaemia, history of cerebroavascular accidents, diabetes mellitusb) Increased age,, ischaemic heart disease, hypertensionc) Tobacco smoking, hyperhomocysteinaemiad) Increased age, male, obesitye) All of the above

MCQ QUESTION

Which of the following are all risk factors for peripheral artery disease?a) Hyperlipidadaemia, history of cerebroavascular accidents, diabetes mellitusb) Increased age,, ischaemic heart disease, hypertensionc) Tobacco smoking, hyperhomocysteinaemiad) Increased age, male, obesitye) All of the above

MCQ QUESTION

Within the arterial system of the lower limb, what is the most common site for thrombosis formation?a) Aorto-iliac segmentb) Femoral-popliteal segmentc) Femoral-tibial segmentd) Infra-popliteal segmente) Iliac artery

MCQ QUESTION

Within the arterial system of the lower limb, what is the most common site for thrombosis formation?a) Aorto-iliac segmentb) Femoral-popliteal segmentc) Femoral-tibial segmentd) Infra-popliteal segmente) Iliac artery

MCQ QUESTION

Within the lower limb arterial tree, what is the most common site for an emboli to lodge?a) Abdominal aortab) Iliac arteryc) Femoral artery bifurcationd) Popliteal arterye) Fibular artery

MCQ QUESTION

Within the lower limb arterial tree, what is the most common site for an emboli to lodge?a) Abdominal aortab) Iliac arteryc) Femoral artery bifurcationd) Popliteal arterye) Fibular artery

COMMON SITES OF THROMBUS FORMATION & EMBOLI LODGEMENT IN THE LOWER LIMB

COMMON SITES OF THOMBUS FORMATION Femoro-popliteal segment

(most common) Aorto-iliac segment

EMBOLI LODGEMENT SITESWhere arteries bifurcate/narrow Femoral artery bifurcation

(43%) Iliac artery (18%) Aorta (15%) Popliteal artery (15)

INVESTIGATIONS- IMAGING

NICE GUIDELINES + ACCF/AHA GuidelinesFurther investigation may be considered in those for whom revascularisation is being considered

Duplex ultrasound: First line to define sties and degrees of stenosis and for routine surveillance after endovascular interventions

Magnetic resonance angiography: to people with peripheral arterial disease who need further imaging before considering revascularisation

Computer tomography angiography: for people whom need further imaging (after duplex) if MRA is contraindicated or not tolerated

Digital-subtraction angiography (God standard) used if endovascular intervention is considered

MANAGEMENT

Non-pharmacological Smoking cessation Control hypertension Supervised exercise program- to

develop collaterals Control obesity- low salt, low fat, mod

sugar intake (NHMRC 2003) Active treatment of diabetes-

including foot care

Pharmacological Pain relief: Cilostazol

(phosphodiesterase III inhibitor, vasodilator and antiplatelet)

Antiplatelet therapy: Aspirin Clopidegrol if unable to tolerate

Lipid lowering therapy: statin ACE inhibitor

NICE GUIDELINES: advice, support and treatment regarding the secondary prevention of cardiovascular disease

MCQ QUESTION

Which of the following patients with lower limb arterial disease would be suitable to consider surgical management?a) Patient with newly diagnosed peripheral arterial disease with a ankle-brachial index of 0.7

who is unable to walk more than 200m to the bus-stop due to significant calf painb) Patient with ankle-brachial index of 0.95 in his left legc) Patient with congestive cardiac failure (class IV) diagnosed with lower limb arterial

disease 5 years ago , managed with pharmacological and non-pharmacological therapies with ongoing pain in his right calf with walking limiting his ADLs

d) Patient diagnosed with lower limb arterial disease 5 years ago, managed with pharmacological and non-pharmacological therapies with ongoing pain in his right calf with walking limiting his performance of ADLs

MCQ QUESTION

Which of the following patients with lower limb arterial disease would be suitable to consider surgical management?

a) Patient with newly diagnosed peripheral arterial disease with a ankle-brachial index of 0.7 who is unable to walk more than 200m to the bus-stop due to significant calf pain

b) Patient with ankle-brachial index of 0.95 in his left legc) Patient with congestive cardiac failure (class IV) diagnosed with lower limb arterial disease 5 years

ago , managed with pharmacological and non-pharmacological therapies with ongoing pain in his right calf with walking limiting his ADLs

d) Patient diagnosed with lower limb arterial disease 5 years ago, managed with pharmacological and non-pharmacological therapies with ongoing pain in his right calf with walking limiting his performance of ADLs

REVASCULARISATION PROCEDURES

Indications Patient is significantly disabled by

claudication Symptoms unresponsive to exercise and

pharmacologic therapy Patient likely to benefit from an

improvement in claudication Ie. Exercise tolerance not limited by another

cause such as angina, heart failure, COPD Preferably proximal to distal disease

PERCUTAENOUS TRANSLUMINAL ANGIOPLASTY

Lesion identified on duplex U/S or arteriography

Guidewire entered through femoral artery, lies over stenosis

Balloon catheter passed over wire into position balloon inflated crushes atheroma relieves obstruction

PERCUTAENOUS TRANSLUMINAL ANGIOPLASTY

Best candidates for angioplasty and stenting Younger (<50) Stenosis not occlusion Short segment disease (<20cm) Non calcified lesions Large-vessel involvement (aortic-iliac disease) Concentric lesions No diabetes Normal renal function

Complications Arterial rupture Groin haematoma Pseudoaneurysm Arteriovenous fistula Thrombotic occlusion/distal embolization

limb loss

SURGICAL MANAGEMENT :BYPASS GRAFT

Best candidates/indicationsNot suitable for PTA Long segment Multifocal stenosis Eccentric calcification Long segment occlusions

COMPLICATIONS

Early (<30 days) Haemorrhage Thrombosis of reconstructed vessel or embolism into limb vessel distal ischemia limb loss Graft infection SepsisLong term Graft occlusion Anastamotic break down Re-stenosis

SURGICAL MANAGEMENT: THROMBOENDARTERECTOMYRemoval of atheromatous plaques and thrombus from the aorta and iliac arteries Rarely used except femoral

with or without profunda plasty For short, localised lesions No evidence to support over

angioplasty (Cochrane review, 2014)

SURGICAL MANAGEMENT- SYMPATHECTOMY

Procedure Excision of lumbar sympathetic

chain or Translumbar injection 6% phenol

To relieve early resting pain to skin No effect on degree of

occlusion/stenosis

SURGICAL MANAGEMENT- AMPUTATION

INDICATIONS Extensive tissue loss Fixed flexion deformities Paresis of the extremity Refractory ischaemic pain

Annual amputation rate in patients with chronic limb ischaemia: 25%

PLAN

Doug to trial basic medical therapy R/V in 6/12 to assess progress

? Vascular referral for possible surgical or endoscopic management if unresponsive to basic medical therapy

2 years later….

PHYSICAL EXAMINATION- LOWER LIMB EXAMINATION

Observation Pallor right foot and distal leg Skin- thin, shiny, loss of hair to

toes Nails- brittle, hypertrophic and

ridged ulcers between 1st and 2nd toes

right foot Gangrenous distal toes and heel

PALPATION Feet cold to touch Capillary refill RLL 8 seconds Peripheral pulses

Femoral- reduced on right Popliteal- Reduced on right Dorsalis pedis-Reduced on left, absent on

right Posterior tibial- reduced on left, absent on

right

PHYSICAL EXAMINATION- LOWER LIMB EXAMINATION

Buuerger’s test: positive right foot Pallor on elevation to 14 degrees Dusky pink when lowered to dependent position

ANKLE SBP Left: 60mmHg Right: 23 mmHg

BEDSIDE ABI Left: 0.7 Right: 0.30

NEUROLOGY EXAMINATION sensory loss dorsum right foot No gross motor loss SLR- NAD

AUSCULTATION Bruit over right femoral artery

CRITICAL LIMB ISCHAEMIA

Where arterial insufficiency is so severe that it threatens the viability of the foot or leg Usually due to multiple lesions affecting different arterial segments

Ischemia resulting in: Persistently recurring resting pain requiring regular analgesia for >

2 weeks and/or Tissue loss (ulceration o gangrenes) plus Ankle-systolic pressure <50mmHg

(Quick, Reed et al. 2014)

MANAGEMENT

(Beard 2009)

FOLLOW UP

Referred to local hospital reviewed by vascular surgery

Had a aorto-bifemoral bypass graft

Ongoing management

• Postoperative duplex surveillance to monitor for re-occlusion

• Maintain non-smoking status• Antiplatelets- aspirin• ACE inhibitors• Statin• Exercise• Weight control

TAKE HOME MESSAGES

Know the characteristics that differentiate arterial, vascular and neuropathic causes of lower limb pain (see table)

Basic medial treatment as first line management for intermittent claudication: aim to reduce cardiovascular risk factors Smoking cessation Diabetes management Optimise weight Exercise Hypertension management Pharmacological management- ACEI, antiplatelet (aspirin), lipid lowering therapy (statin)

Critical limb ischaemia definition Resting pain requiring analgesia > 2 weeks AND/OR tissue loss AND ankle-systolic pressure <50mmHg

REFERENCES

Anderson, J. L., et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines." Journal of the American College of Cardiology 61(14): 1555-1570.

Au, T., et al. (2013). "Peripheral arterial disease Diagnosis and management in general practice." Australian Family Physician 42: 397-400. Beard, J. D. (2000). "Chronic lower limb ischaemia." BMJ 320(7238): 854-857. Callum, K. and A. Bradbury (2000). "Acute limb ischaemia." BMJ 320(7237): 764-767. Garden, O. J. (2007). Principles and practice of surgery. Edinburgh, Churchill Livingstone/Elsevier. Grenon, S. M., et al. (2009). "Ankle–Brachial Index for Assessment of Peripheral Arterial Disease." New England Journal of Medicine 361(19):

e40. Henderson, J., et al. (2013). "Peripheral arterial disease." Australian Family Physician 42: 363-363. NICE (2014) Lower limb peripheral artery disease: Diagnosis and Management. Peripheral artery disease

;https://www.nice.org.uk/guidance/cg147 National Health and Medical Research Council. Dietary guideliens for Austrlaian adults. 2003. Available at

www.nhmrc.gov.au/_files)nhmrc/publications/attachments/n33.pdf [accessed October 2015] Quick, C. R. G., et al. (2014). Essential surgery: problems, diagnosis, and management. Edinburgh, Churchill Livingstone, Elsevier Sharma, A. M. and H. D. Aronow (2012). Lower Extremity Peripheral Arterial Disease, INTECH Open Access Publisher. Thompson, J. N. and M. M. Henry (2005). Clinical surgery. Edinburgh, Elsevier Saunders.