Download - Week 27- Case 2
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.