59 years old male patient with presentation of right leg pain on walking and history of back pain and previous disc surgery. Presented to you in vascular clinic. He was told that his leg pain is due to his back.
Q1: How would you approach this case?
This patient had normal leg raising test. He has no ongoing back pain. His pain gets better on rest and his right LL has no pulses below the femoral pulse. No tissue loss or ulcers or tissue necrosis
He is Diabetic and smoker and works as banker. With normal blood tests.
ABPI is 0.7 on the right leg
Questions?
-To what degree do you agree with previous diagnosis of neurogenic claudications ?
-Do you need any further investigations?
-What would be your treatment plan?
-How would you approach the patient in term of patient education regarding her condition and the set expectation for her prognosis?
part 2 of case 1
- This patient came to you one year later with ulcer on his tip of his right big toe that has not healed for 6 weeks
- How would you approach this?
A approach to the patient
1st with history taking for hypertenion-DMcontrolled or not
–smoking- hyperlipidemia
– We will ask for sedentary lifestyle
any cardiac history
drug history is also important for blood thinners
Pain analysis: cramping We will ask about the onset, course and duration of his symptoms, if it improves by rest and increase by exertion, it is more likely to be CLI. If it improves by leaning forward or climbing uphill or pushing trolley, it is more likely to be neurogenic
any ulcers or wounds
We will ask about the level of his claudiactions to the level of the suspected arterial lesion, i will also ask about his claudication distance or rest pain
EXAMINATION:
I will check his pulses from proximal to distal
Look for brittle nails, hair loss, ulcers or scars , color changes, capillary refilling, temperature compared to the other leg, interdigital infection, muscle wasting, leg swelling, sensory and motor assessment, then I will do Buerger’s test.
Blood pressure can be measured and regularity of pulse can be assessed
Also spinal examination can be tried
INVESTIGATION
ABI and duplex us for the arterial system
Also I will ask for some blood tests
– CBC, lipid profile
– HbA1c if the patient is known diabetic
kidney functions only before a CT angio
A2 it is mostly non neuropathic pain as the patient has claudication pain ,absent distal pulse ,decreased ABI
A3 as the patient only claudicant ,only ABI needed and arterial duplex
A4 i will consider conservative treatment like smoking cessation ,control DM ,HTN , and hyperlipemia
medical treatment like antiplatelet -statin -colistazol
exercise therapy
A5 i will counsel the patient he has a chronic limb ischemia and he need to stick to the conservative treatment and foot care
and utgent referal if he has any wounds or gangrene
A6 i will asess patient unhealed wound and see if it infected or not
assess patient pulsation and ABI
imaging like duplex – xray foot – ABI
cta for asessment of level of occlusion
consider treatment option like conservative treatment and control of risk factors
medical treatment like antiplatelet -statin -colistazol
consider revascularization option like angioplasty or bypass according to level and length of obstruction
foot offloading
wound care and dressing
debridment or minor amputation if needed
A1: Full history including Smoking Index, co-morbidities, previous surgeries, and pain characteristics and relieving/aggravating factors. Followed by Duplex assessment
A2: Don’t agree as no pusle felt below femoral, his ABPI is 0.7, history of diabetes and smoking, and patient has a sedentary job.
A3: Arterial duplex Ultrasound and CT. Angiograpgy
A4: Refer to endocrine specialist to have better control of diabetes,
Advise to cessate smoking,
Exercise,
Cilostazol and Statins
Repeat history assessment of previous year, repeat CT. Angio of arterial tree and consider interventions after assessment
1st pain is not matching with neurogenic pain as neurogenic pain appear during up hills not normal walking .
—Pt need further investigation
Hba1c
Lipid profile
S.creat
Duplex for arterial system
——ttt plan
-life style modification
Stoppage of smoking ,starting exercise
– glycemic control
– BP control
– anti platelet
-statin
-cilistazole
———-
Pt education for risk of his case
Alarming signs of his condition(ulcer,dry gangrene,rest pain)
Control his sugar
Stop smoking
Starting exercise
Tolerate his medication
And follow up
———-
Ulcer not responding to ttt is sign og CTLI that need urgent angiography and revascularization, pain control and dressing of ulcer
I dont agree with the diagnosis of leg pain due to problem of the back as the straight leg raising test is not posittive and the pain is not relieved by leaning dorward but by rest which is more common with arterial claudication
– Yes, I need further invesigation as Duplex areterial system and if is is not conclusive I will jump to CTA
– The treatment plan will be conservative managment with life style modification by adjustment of level of blood sugar ans control of hypertension,cessation of smoking, Statins, antiplatelt agents, low dose anticoagulant may be used also, vasodilators as cilostazol ,Exercise therapy to increase the caludication distance
– I will tell him that life style modfication is cornerstone of his treatment and to stop smoking, lose weight, modify his dietry habits, continue on medication, take care of his leg by daily inspection for any ulcer, wearing offloading shoes, never to walk on bare foot
I will tell him that he is propably on the way to have CLTI and that he will be candidate for bypass or angioplasty , it may end in ampuyation so he must come to clinic if he statrs to have rest pain, any unhealed ulcer or tissue loss
– The patient probalbly has CLTI so I will examine the ulcer it may be pressure ulcer (neuropathetic) which needs care and offloading
If it is punched out and painful it is arterial ulcer that needs intervention
So I will order a duplex commenting on the the artrtial tree lesio, S.cr for CTA
1
first we should go for detailed history to differentiate vascular from neurogenic pain
, comprehensive vascular examination and accordingly we could go for proper management
Life style modification as smoking cessation and glycemic control
walking exercises at least 3 times per week to improve claudication distance
best medical therapy (BMT): including antiplatlets, statins and vasodilators
the patient should know what the nature of her illness is and the diagnosis and how to deal with her symptoms and the benefits of the treatment and when to reconsult or if she need an intervention
2 approach by :reasseement of the general condition including general examination and local vascular examination including ABPI and for sure will be less than the last one
order CTA , serum cr level and arrange for intervention as soon as possible preferably within 2 weeks according to the site and size of the lesion whether endovascular , open or hybrid procedure
Q1 : l would take a good medical history , good analysis if the pain.
Vascular examination, and arterial duplex if needed.
_ I don’t Agree with the previous Diagnosis as a neurological pain.
This is Arterial claudication of PAD confirmed by examination and ABPI less than 10.
_Arterial Duplex Ultra sound.confirms the Diagnosis and better Determine the pathology.
_Conservative treatment: Life style modification: sessation of smoking and Exercise and best medical ttt.
_Health education about the importance of Adhering to best medical ttt and life style modification. As the next step in management will be invasive intervention . And Threatening limb Ischemia is high Morbidity and mortality rates.
Part 2 of Case 1 :
Patient is for intervention , i will prep for Angioplasty.
A1
— I don’t agree with neurogenic claudication as the patient as a patient has features arterial insufficiency as developing pain while walking and pain is relieved the by resting where is absent infra femoral pulses and APBI below .7
– I would order duplex ultrasonography a commenting on their patency , wave form and peak systolic velocity in the arterial three starting from the femoral artery to the popliteal and the tibials ; and the presence of atherosclerotic plaques or significant stenosis
— first of all smoking sensation and adequate control of blood pressure and diabetes if present secondly patient will be prescribed anti-platelet and statin.
— the condition of the patient is chronic condition it has several predisiposing factors including the diabetes, hypertension, and smoking. Patient needs exercise program, whether supervised or walking for 30 minutes 3 to 4 times weekly for increasing claudication distance with special attention to sensation of smoking with body replacement with nicotine batches or varencline etc… and I would explain to the patient that treatment of his condition needs cooperation and the compliance as it’s a chronic one, and it would be improved with lifestyle modification and treatment,
A2
— now the patient has critical limb ischemia. He needs at the beginning, creatinine and CTA on both lower arterial system with processing. Furthermore, he needs revascularization, either using plasty or bypass surgery, according to the stenotic lesion and the presence of distal run off.
of course, need a new measurement of a ABPI and a new for lab with echocardiography for preparation of the intervention.
Dear All,
There are very good answers I really recommend that you guys read each other answer so it is brainstorming activities. And check how far do you agree with your colleagues.
I just want to stress that for non disabling claudication there is no indication to do any investigation apart from ABPI. Generally speaking you do investigation either to diagnose a condition or to plan for treatment. In part one of this case you could establish the diagnosis based on symptoms and ABPI. There is no indication for any further imaging. specially with cost and side effect of the these investigations.
Regarding Part two. Yes you need now to get further investigation to plan for treatment giving the patient now is moved to CLTI category. It is important to consider pain management as part of your treatment plan.
A1: Full history including Smoking Index, co-morbidities, previous surgeries, and pain characteristics and relieving/aggravating factors. Followed by Duplex assessment
A2: Don’t agree as no pusle felt below femoral, his ABPI is 0.7, history of diabetes and smoking, and patient has a sedentary job.
A3: Arterial duplex Ultrasound and CT. Angiograpgy
A4: Refer to endocrine specialist to have better control of diabetes,
Advise to cessate smoking,
Exercise,
Cilostazol and Statins
Part2: Repeat history assessment of previous year, repeat CT. Angio of arterial tree and consider interventions after assessment.
A1 history taking of the patient
how many ciggarette per day
asking about any other comorbidities like diabetes, hypertension , hyperlipidemia
characteristics of pain what increase or what decrease
A2 i dont agree with the dignosis
vasculogenic claudications
investigations arterial dupplex U\S
C.T angiography
management
cessation of smoking
control of diabetes
excerise
best medical treatment for chronic ischaemia : antiplatelet , anticoagulant,
statins
part 2
full history taking of the previous duration
c.t angiography of the arterial tree
acccording to findings of the angiography the decision will be taken
mostly this patient will need endovascular intervention
A1: At first, I would take a full medical history including his medications and previous surgeries then I would start to get more information about type of pain, how it is provoked, and how it is managed either by rest only or leaning forward, is it unilateral or bilateral and the site of leg pain and through examination I would assess the presence of chronic ischemic changes, the pulses from proximal to distal, muscle power and level of sensory deficit
A2: regarding the patient’s past and social history and his examination this directs me to the fact that the patient’s complaint is due to chronic ischemia and I would proceed with further investigations to assess the level of arterial flow insufficiency in the form of arterial duplex for lower limb together with laboratory investigation to search for anemia, Hb A1c to review the glycemic control in addition to renal function tests. My treatment includes first explaining my diagnosis and educating the patient about his condition and advising against smoking and recommending strict glycemic control in addition to walking exercises and how he should gradually increase his walking distance also I would start aspirin and statins
A3: complete reassessment of the patient to evaluate the progress of the disease and ulcer assessment regarding ischemia, infection, or neuropathic trophic changes and ask about the presence of rest pain in addition to how she is adhering to the treatment plan this is followed by new duplex evaluation and CT Angio and as a result of developing tissue loss I would schedule him for revascularization according to her fitness and TASC classification either open or endovascular repair
Q1:History taking: Asking about smoking …amount of ciggarettes smoked
Hypertention , diabetes mellitus, hyperlipidemia , cardiac condition and medications taken.
Asking about the type of pain, character of pain….what increases it , what decreases it and its duration.
By examination: inspecting foot for ulcers, gangrene, loss of hair, toe web spaces and shiny skin
palpating the distal arteries of feet , checking capillary refill , warmth of foot , sensory and motor powers of lower limb.
Straight leg raise test for neurological claudication.
ABPI measurement for degree of ischemia.
I totally disagree with diagnosis of neurogenic claudications …It is a vascular cause of claudication probably chronic ischemia.
Risk factors: Diabetic, smoker
Normal straight leg raising test.
Pain relieved by rest not by leaning forward.
Pulses not felt distally.ABPI is 0.7…. Moderate ischemia.
Further investigations:
Non invasive imaging…Arterial duplex U/S
Life style modifications: Cessation of smoking, Control of DM, exercise by walking.
Medical treatment: Vasodilators, antiplatelets and statins…and follow-up.
I will explain to her that exercise and walking will improve the claudication pain and distance…in regards the collaterals.
Strict control of DM and cessation of smoking.
Further investigations: Plain X-ray of foot to exclude osteomyelitis.
CT angio for revascularization eith endo or open surgery.
-To what degree do you agree with previous diagnosis of neurogenic claudications ?
less likely to be neurogenic but kept in mind as an additional cause.
-Do you need any further investigations?
Absolutely, Duplex US then CT angiogram
-What would be your treatment plan?
Conservative treatment by controlling risk factors, supervised or unsupervised exercise, aspirin, statins.
-How would you approach the patient in term of patient education regarding her condition and the set expectation for her prognosis?
controlling risk factors is very critical to his case, so we encourage exercise and walking, stop smoking, low fat diet, close control of DM, follow up regularly in the clinic, take care of your foot regarding redness, swellings, colour changes or any abnormality.
Note that, if recommendations not followed, case may worsen, pain may increase and may affect work or foot may appear discoloured or ulcerated.
This patient came to you one year later with ulcer on his tip of his right big toe that has not healed for 6 weeks
I will retake history and clinical examination to confirm the prognosis after the first visit
then CT angiogram is important after confirming good renal function,
I will recommend BMT and continuing exercise and controlling DM and stop smoking.
According to CT findings, plan of treatment will be tailored.
Regarding his age, smoking, DM, his job, pain appears with walking and disappears by rest his pulse wise, and ABI make it ischeamic not neurogenic claudication
I will go for arterial duplex to have information about sites, extention and degree of stenosis or occlusions, wave form, and PSVs for as a base and for future followup or events. Note: he is assumed not having disabling claudication intervening with his work as a banker so duplex will be enough as a base and will start conservative ttt
Treatment will start by life style modification encouraging regular walking exercise, body weight control, DM control, smoking cessation,
Antiplatlet, high dose statin, and cilostazole if not contraindicated and neurotonics
My approach will be discussing risk factors of atherosclerosis and its complications on herat, brain, and kidneys, importance of those risk factors control especially smoking, blood glucose control and routine follow ups by ECG, KFts, Retinoscope
Also discussing foot care and suitable footwear, hygiene, and daily foot inspection
Also importance of medications, walking exercise and importance of developing healthy collateral circulation to improve claudication distance and shorten period of rest, importance of smoking cessation and DM control to avoid gangrene or Diabetic foot problems that may reach amputation
With an ulcer not healing for 6 w he has CLTI that on WIFI class needs revasc and ulcer care
Revasc plan : clinically pulse level, bodyweight and obesity, his METS score
preop CBC, INR, KFTs, HbA1c, echo, ABI, duplex, saph vein map.
ACC to Cr level we will order a CTA OR MRA and to plan surgery and type of bypass
Or endovasc approach regard access and tools
Ulcer care: depth, infection, Osteomyelitis, culture and sensitivity and need for depridement or distal phalynx ampu and proper dressing
Q1: taking full history; smoking how many and for how long ask also about alcohol , if he has hypertension and controlled on which medication, if he is diabetic and last HBA1c and his lipid profile and asking if he has any cardiac insult before and if he has one of his family had the same problem
asking about the pain when it comes and what increase and what makes it better or disappear
by examination inspect both lower limbs for any ischemic manifestations or tissue loss or gangrene then checking his pulse bilaterally then doing ABI even if the pulse is present but after exertion to see if it will decrease after exertion
then i will do duplex ultrasound assessment
Q2: i totally disagree with diagnosis as neurogenic claudication its totally arterial claudication as the pain appears with walking and disappears with rest and their is no pulse distally and his ABI is 0.7 and their is normal leg raising test
Q3: Duplex ultrasound assessment to see the level of affection of his arterial tree and if it above the knee i can go for CTA to assess all the arterial tree
Q4: first i will offer him best medical therapy for 6 months starting with life style modification to stop smoking and control his diabetes and supervised exercise and clistazol to increase his walking distance and statins
if no improvement i will go for intervention according to the CTA results
Q5:i will tell him that claudication distance could increased with this treatment and strict glycemic control and daily inspection of his foot and his pain will improved with time according to the collateral development and that we will intervene in case of tissue loss or gangrene
Q6:the same like before in the examination of the pulse and will examine the ulcer if infected or not and will do x ray to assess the extension of the infection and exclude the osteomyelitis and will do ABI to see if it decrease then duplex US and CTA if intervention is planned
Negative SRL test and lost infra inguinal pulsations with ABPI 0.7, so spinal cause is unlikely and vascular pathology is the cause
Arterial duplex CTA and conventional angiography
Conservative treatment is recommended in the form of life style modifications smoking cessation exercise bl sugar control along with medications anti platelets statins vasodilator
Inform the patient how to improve the symptoms and increase the collateral circulation. Avoid complications and the precautions for that as foot care nail trimming web spase care
Inform the patient about warning signs that needs consultation including rest pain ulcers coolness of foot foot infection and gangrene or color change
After a year with unhealed ulcer CLTI is cosidered so intervention surgical bypass or endovascular after confirming the diagnosis by clincal examination to confirm the pulse condition and ABPI to see the progress of the disease. duplex arterial and venous mapping in case of GSV conduit and CTA MRA to get a complete overview of the inflow and runoff. Xray foot to exclude OM
Referral to the anesthesiologist for operation fitness
Care of the ulcer
Q2
I don’t agree
Dt no pulse below femoral
ABPi 0.7 =PAD
And has history of DM and smoking
And his work manner is steady
..
Q3
YES I NEED DO CT ANGIO FROM arch of aorta till both lower limbs
…
Q4
I will confirm that he doesn’t have rest pain and
UP TILL NOW PT is CLLI
So I will go for conservative
by now
By giving him vasodilators and antiplatelts and stations and cilostazol
Visite endocrinologist for good adjust DM
Stop smoking
And do regular exercise like walking 30 min
….
Q5
Now his condition is mild to moderate..
He must know that his disease is not curable
And know the amount of blood which reach his ll is limited due to obstruction on blood tubes
Would know that his adjust his DM is very important and change life style and stop smoking
And there is red flags
Rest pain (awake him from sleeping)
Or leg ulcer
Be aware that any injury in his legs would be difficult to healed
Never injury his ll
And he will need ANGIOplasty intervention within 2 weeks
If he is Muslim, must to dry between his toes
After Ablution
……
Q6
I will reassessment the pt
By peripheral arterial examination
Level of pulse (still there is femoral or no)
Capillary refilling
Motor
Sansory
ABPI
I would need duplex
Fbc
Urea creat
Crp
X ray on foot AP and Lat
RBG
Then revascularization then debridement on table
Revascularization by ANGIO or bypass
According to pt condition
And lesion length
By CT
Q1: How would you approach this case?
We will start with HISTORY TAKING:
– Is he known hypertensive or diabetic, for how long, on which medical ttt, is his condition (HTN or DM) controlled or not
– Is he a smoker, for how long, how many cigarettes per day, has he considered quitting smoking
– Is he known dyslipidemic, on statins or not, known family history of dyslipidemia
– We will ask about his occupation for sedentary lifestyle
– Does he have any cardiac of cerebrovascular event , does he take any blood thinners (if yes ask about the cause and the dose)
– Pain analysis: nature of pain; is it cramping, burning, or dull aching. We will ask about the onset, course and duration of his symptoms, if it improves by rest and increase by exertion, it is more likely to be CLI. If it improves by leaning forward or climbing uphill or pushing trolley, it is more likely to be neurogenic
– Is there any foot burning sensation at night while sleeping or it is just only the leg pain that happens with walking
– We will ask about the level of his claudiactions ( calf, thigh, buttocks) to get a hint about the level of the suspected arterial lesion, i will also ask about his claudication distance
EXAMINATION:
I will check his pulses from proximal to distal
Look for brittle nails, hair loss, ulcers or scars , color changes, capillary refilling, temperature compared to the other leg, interdigital infection, muscle wasting, leg swelling, sensory and motor assessment, then I will do Buerger’s test.
Blood pressure can be measured and regularity of pulse can be assessed
Also spinal examination can be tried
INVESTIGATIONS:
After examination I will need noninvasive investigations to confirm my diagnosis
– I will ask for ABI and duplex us for the arterial system
Also I will ask for some blood tests
– CBC, lipid profile
– HbA1c if the patient is known diabetic
– I will ask for RBS if he is not known to be diabetic. If his RBS came elevated I will ask for fasting blood sugar,2 hours postprandial and HbA1c
– I will ask for kidney functions only before a CT angio is indicated unless the patient is hypertensive and/or diabetic as a screening for hypertensive or diabetic nephropathy
-To what degree do you agree with previous diagnosis of neurogenic claudications ?
Given that he has no ongoing back pain, that he has the typical manifestations of claudication pain which increases by walking and gets better on rest, and the evident absent popliteal and distal pulsations, also given the risk factors of diabetes, smoking and sedentary lifestyle as a banker
And most importantly his ABI of 0.7
– these points are enough to diagnose him with chronic limb ischemia favoring vascular caludication over neurogenic claudication.
However, The patient is not CLTI as there is no rest pain mentioned or any tissue loss or ulcers
-Do you need any further investigations?
Rt LL Arterial duplex US is another non invasive investigation can be done which can give an idea about his arterial tree regarding calcification, stenotic lesions, presence of aneurysm, PSV and wave-pattern
I will not ask for a CT or MR angiogram unless intervention is indicated
-What would be your treatment plan?
Lifestyle Modifications:
– Patient will counseled to quit smoking and will be referred to specialists
– Patient will be asked to abandon his sedentary lifestyle and do exercises even if it is just walking for 3 hours a week ( supervised exercise therapy)
Patient education:
– Patient will be asked to closely monitor his blood sugar and to seek regular follow up visits with his endocrinologist
– Patient will be asked to take care of his feet and to wear protective socks and closed shoes with daily feet inspection for signs of inflammation to avoid the risk of diabetic foot infections.
Medical ttt:
– Patient will be prescribed best medical treatment in the form of double anti platelet. cilostazol also can be prescribed to improve his claudication distance. Statins also will be prescribed if he his labs showed dyslipidemia. Analgesics can also be prescribed
– If there no improvement and the patient complains that claudication interferes with daily activities, angioplasty can be offered
Claudication is not an indication for angioplasty. However, it can be offered to active patients where claudiaction affects their lifestyle
-How would you approach the patient in term of patient education regarding her condition and the set expectation for her prognosis?
– The patient will be advised to strictly adhere to the previously recommended treatment plan to prevent disease progression otherwise he may suffer from rest pain, ulcers, gangrene or even life-threatening sepsis giving us no option except lifesaving amputation
– Explain the possible interventions ( angioplasty and bypass) and their risks if his case worsened
– He will be informed that his condition is a chronic one which will require a lifelong follow up at our outpatient clinic
– He will be advised to seek immediate medical consultation with the earliest sign of infection
part 2 of case 1
* This patient came to you one year later with ulcer on his tip of his right big toe that has not healed for 6 weeks
* How would you approach this?
The patient came presenting now with CLTI,
– Pt will be asked about his compliance to ttt
– I will repeat the previous examination adding examination of the ulcer (site, size, edges, floor, infection
– I will order new labs ( CBC, kidney functions, INR, virology, HbA1c, lipid profile, CRP)
– I will ask for a new ABI expecting it will be 1.4 as he is diabetic
– CT or MR angiogram according to kidney functions
– ECG & Echo
– Daily dressing. Debridement is risky before angioplasty
– Urgent revascularization within 2 weeks followed by debridement
Very good and comprehensive answer but could you explain why (double anti platelet) could you check EVES guidelines or NICE guidelines and respond to this question with evidence.
Now after one year of medical treatment the appearance of toe ulcer resisting healing for 6 weeks this patient become CLTI that requires different strategy during treatment .. at first I will exam the ulcer for signs of infection as erythema, discharge and induration
Then I will ask for full lab as CBC, LFT,KFT and CRP
To sea if there is systemic affection
X ray is also valuable to exclude OM of bone in the toe
I will ask for new Arterial doppler and CTA and will plan the intervention needed for revascularization according the result
Thanks Mahmoud, Good answer, but why both CTA and duplex?
1 Approach this case by
full history :social , medical and surgical , onset and course of the pain , what increase and decrease the pain
Full examination: inspection for signs of chronic ischemia , palpation of pulse on both lls neurological examination
I don’t agree with the neurogenic diagnosis
Further investigation 1st is arterial duplex if not conclusive CTA
Ttt plan as a claudication pain
Control of risk factors , medical ttt and exercise ttt if not improved after 6 months and claudication interfere with daily activities then intervention
Patient education
Told him that it’s a chronic ischemia that causes the pain but it’s an early stage which may improve with strict control of risk factors , medical ttt and exercise if not improved intervention will be needed
It may progress to other stages such as ulceration or gangrene which will need intervention mostly
2 approach
After history and examination
Put the pt on WIFI classification and grade of ischemia according to ABI then know if revascularization is needed or not according to guidelines
If intervention is needed arterial duplex if not conclusive CTA
History talking regarding pain analysis
Risk factors as DM HT cardiac problems smoking any+ve families history
Examination of pulses and ABI measurements for assessment of pad
Regarding agreement with neurogenic claudication as previously diagnosed presence of both conditions is Not uncommon
Arterial duplex us is non invasive and informative investigation+ hga1c and lipid profile
ttt plan
Best medical ttt risk factors control+aspirin+anti dyslipidemic agent+vasodilator
This PT should be educated about risk factors and how it affects his disease
Diseases is progressives unless risk factors is controlled
PT need strict follow up to detect any deteriorations and needs for intervention
Like claudication becomes disabling
Rest pain and any unhealed ulcers or gangrene
ABI assessment+CTA
Then according to the results intervention is chosen PTA vs surgery
Q1: I would approach this case through full medical history and medical examination as it has complex history
1. Detailed History:
Assess the exact nature of pain: Is it cramping, burning, or aching?
the pattern of pain relief: Is it relieved by rest or by changes in posture (e.g., flexion of the spine)?
Confirm the duration and progression of symptoms.
Explore any history of intermittent claudication (vascular) or neurogenic claudication (spinal).
2. Physical Examination:
Vascular Assessment:
Palpate all pulses (femoral, popliteal, posterior tibial, dorsalis pedis).
exact ankle-brachial pressure index (ABPI) on the left side for comparison
Look for skin changes: pallor, hair loss, coldness, or trophic changes in the limb.
Neurological Assessment:
Assess motor strength, sensation, and reflexes in the lower limb.
Straight leg raising test (normal).
at This Stage:
The absence of back pain, normal straight leg raise test, and reduced ABPI (0.7) strongly suggest vascular claudication rather than neurogenic claudication. The absence of pulses below the femoral artery further supports arterial insufficiency as the likely cause.
—
about the previous diagnosis :
Given the absence of ongoing back pain, normal leg raising test, and the presence of significant PAD, it’s unlikely that neurogenic claudication is the primary cause of the patient’s leg pain. The diminished pulses and low ABPI strongly suggest that it is a vascular claudication.
—
further investigations?
Yes, I need further investigations :
1. Imaging:
Doppler Ultrasound of the lower limb arteries to assess arterial flow and identify significant stenosis/occlusions.
CT Angiography (CTA) or MR Angiography (MRA) to map the extent of peripheral arterial disease (PAD).
if vascular imaging fails to explain symptoms I will consider MRI spine and nerve conduction study of this lower limb
—
What would be your treatment plan?
Medical Management:
1. Lifestyle Modifications:
Smoking cessation (essential to halt disease progression).
Supervised exercise therapy for PAD (e.g., walking programs).
2. Medications:
Antiplatelet therapy.
Statins: For lipid lowering and plaque stabilization.
Cilostazol: To improve symptoms of claudication.
As the patient is claudicant no current need for endovascular/surgical Intervention:
—
How would you approach the patient in terms of education and prognosis?
Regarding condition education:
Explain the diagnosis of PAD and its implications.
explain the role of lifestyle changes, particularly smoking cessation and exercise.
Discuss the importance of glycemic and lipid control.
Regarding prognosis: that with proper management, symptoms can improve, and progression can be slowed.
and I will discuss the possibility of needing intervention if symptoms worsen.
It’s important to Set Expectations:
Realistic goals regarding symptom improvement with exercise and medical therapy.
The need for long-term follow-up.
Thanks for very comprehensive answer.
Could you please expand of the indication and clinical questions you are aiming to answer with your radiological investigation?
How would you answer this question from the patient ( what is the chances I can lose my leg with poor circulation condition?)
regarding vascular imaging i need to know exactly the extent of the PAD, and exact sites of stenoses or occlusion, giving an idea about the future need of endovascular or surgical intervention
regarding MRI spine and nerve conduction study, i need to entirely exclude any neurological cause of the pain, as the patient may go with my instructions and management and no improvement will happen if there is a neurological cause behind
I agree that MRI spine would be useful scan as it may change your treatment plan. But how CTA and MRA are going to change your treatment plan. and why you want to do both?
part 2:
firstly I will do full assessment of the patient and the wound (ulcer) as in this patient; the ulcer may be caused by worsening PAD, or uncontrolled DM
regarding the ulcer :
size, depth, edges, and most importantly signs of infection
vascular examination:
re assessment including measuring ABI again is mandatory for detection of worsening PAD
Neurological examination:
for sigbs of sensory neuropathy
Management :
if there is no worsening of his arterial distal runoff or the ABI then the ulcer mostly diabetic foot ulcer which will be treated by good diabetic control and wound care
if the cause is PAD then I will order CTA/MRA and go for intervention either endovascular or surg bypass
as regarding patient education
now counselling is different as now we are talking about tissue loss and high incidence of amputation
Good answer with initial management plan. But, could you please explain why you need both MRA/CTA?
sorry, actually I didn’t mean both, i meant CTA or MRA 😅
Q1. This pain is mostly claudicant pain (cli)
Pain getting worse with walking relieved by rest unlike spinal pain relieved by leaning forward
Q2. arterial duplex firstly needed as radiological investigation then CT angiography maybe needed
Lab lipid profile
HbA1c
S.creat
O3. Best medical therapy
Smoking stoppage
Exercise
Antihyperlipidemic
Antiplatelet
Cilostazol
Good diabetic control
If failed with severe claudicant pain angioplasty or bypass surgery
what is the justification for this answer(arterial duplex firstly needed as radiological investigation then CT angiography)
How would you teach your patient about foot care and alarming signs?
Q1 at first i will start by proper history taking i will start by analysis of the complaint as onset, course, duration, releasing and precipitating factors of pain
then i will ask about medical history presence of DM, HTN and hyperlipidemia
i will ask about smoking history and lifestyle habits and if there is a family history of such complaint
then i will proceed with a physical exam of the LL
inspection: for ulcers, skin pigmentation, loss of hair and prattle nails
palpation: for temperature sensation in comparison to the other limb and for level of palpable peripheral pulse
special tests as the burgers test and straight les raising test to differentiate ischemic pain from neurogenic pain
them i will go for investigation as ABPI, arterial duplex US even CTA
……………………………………………………………………
answer 1 : from history only it could be of course neurogenic pain but I shouldn’t give definitive diagnosis from just history taking so as when a physical exam was done it gave us another Possible diagnosis so i disagree with the previous diagnosis
answer 2: yes of course arteria Doppler and CTA are needed
answer 3: ABPI IS 0.7 and there is no tissue loss or rest pain only the pt complains of intermittent claudication so the patient is mild CLI so i will build my treatment plan on that which will be lifestyle modification in the form of stopping smoking, proper control of DM and i will encourage the pt for a supervised training program and lastly i will but the pt on medical ttt according o the guidelines anti platelets and high dose of statins
answer 4: i will inform the patient about the disease’s nature and her stage in the disease which could be managed only by bist medical therapy and proper control of risk factors
and i will educate her about the progression of her disease and the expected outcome if it progresses up to the level of amputation i will educate her about our strategy of treatment when disease progression occurs as angioplasty or even bypass to overcome the occurrence of complications
Thanks for organised answer, regarding answer 2, How would respond to patients son who is a medical student saying ( why do you need CTA knowing that it might affect my father kidney?)
Regarding Answer 4 the son says (my father suffers from anxiety and you are scaring him by mentioning amputation what is the chances this could happen) ( what is the alarming signs that require urgent action from our side)
Regarding affection of kidney function I will say that we could replace it by MRA
Regarding the chance of amputation in a patient with IC of course it is a very small one
And regarding alarming signs I will told him if there is decrease of the walking distance the appearance or rest pain in his feet and if there is an ulcer appears in his feet they should worn about that and seek medical advice
So they ask you why do you need us to do expensive scan and how this will change your treatment plan?
good answer regarding patient education.
History :
complaint : onset , course, duration ,character of the pain , what increase ? like walking up hill or exercise or prolonged standing, what decrease ?limb dependency, rest. site of the pain ? , any tissue loss like gangrene or ulcer ?
swelling
any neurological symptoms: numbness, tingling , muscle weakness
medical history : DM, Hypertension, DVT, hyperlipidemia, Ischemic heart disease , CKD
medication: statins, antiplatelet, anticoagulation, oral hypoglycemic
surgical history: any intervention to the back , did he improve with surgery ? , is it the same pain like the one before the surgery, was he compliant with physiotherapy postoperative
Family history of PAD,VV, aneurysm
smoking , alcohol, occupation
place where he lives ? does he need to climb stairs ?
examination :
general : blood pressure if hypertensive
local: inspection :
hair loss , trophic change like ulcer or gangrene , skin color change, interdigital infection , VV
palpation
pulse , Capillary refilling time , temp, tenderness
Buerger test , ABI
neurological examination
straight leg raising test
investigation
labs : KFT, lipid profile , HBA1c, FBC
radiological: duplex, CTA ,MRA
if neurological pain consider consider MRI
Treatment
life style modification : exercise, smoking cessation , diet
risk factors : blood pressure and blood sugar control
medication : antiplatelets, statin, cilostazole
intervention: if crippling claudication and didn’t improve with medical therapy
angioplasty vs bypass
A1) criteria against neurogenic pain : normal SLR, no back pain
criteria with ischemic pain : absent pulse, improve with rest, risk factors : diabetes and smoking , ABI:0.7
A2)labs : KFT, lipid profile , HBA1c, FBC
radiological: duplex
if intervention is planned : CTA ,MRA (if abnormal KFT)
A3) Treatment
life style modification : exercise, smoking cessation , diet
risk factors : blood sugar control
medication : antiplatelets, statin, cilostazole
as it’s not crippling claudication as he is a banker and no tissue loss , I will not proceed for intervention whether angioplasty or bypass.
A4) He has chronic limb ischemia which means that the blood amount reaching his muscles and tissue is below normal so he feels that pain
with exercise and medical treatment his claudication distance will improve
but that doesn’t mean that he will be cured totally as it’s considered a chronic disease
he should be aware if there is any signs of tissue loss or acute ischemia that he will need to seek medical advice immediately
Thanks for organised answer.
when do you exactly consider claudication is crippling?
if you plan intervention why you need to order both MRA and CTA
I will consider it crippling if it’s affecting his daily activities or his occupation
I will order whether CTA or MRA according to his KFT
in order to have a plan whether to do angioplasty or bypass
by the way, I like your answer for (A4) well done.
thanks a lot for your comment and your kind help
Part 2
I will follow the same approach
investigation
labs : KFT, lipid profile , HBA1c, FBC, ESR, CRP
wound culture and sensitivity
radiological: foot X-ray
duplex, CTA or ,MRA
Treatment
life style modification : exercise, smoking cessation , diet , diabetic shoes for offloading
risk factors : blood pressure and blood sugar control
medication : antiplatelets, statin, cilostazole, broad spectrum antibiotics if infected
intervention: debridement
angioplasty or bypass
History :
complaint : onset , course, duration ,character of the pain , what increase ? like walking up hill or exercise or prolonged standing, what decrease ?limb dependency, rest. site of the pain ? , any tissue loss like gangrene or ulcer ?
swelling
any neurological symptoms: numbness, tingling , muscle weakness
medical history : DM, Hypertension, DVT, hyperlipidemia, Ischemic heart disease , CKD
medication: statins, antiplatelet, anticoagulation, oral hypoglycemic
surgical history: any intervention to the back , did he improve with surgery ? , is it the same pain like the one before the surgery, was he compliant with physiotherapy postoperative
Family history of PAD,VV, aneurysm
smoking , alcohol, occupation
place where he lives ? does he need to climb stairs ?
examination :
general : blood pressure if hypertensive
local: inspection :
hair loss , trophic change like ulcer or gangrene , skin color change, interdigital infection , VV
palpation
pulse , Capillary refilling time , temp, tenderness
Buerger test , ABI
neurological examination
straight leg raising test
investigation
labs : KFT, lipid profile , HBA1c, FBC
radiological: duplex, CTA ,MRA
if neurological pain consider consider MRI
Treatment
life style modification : exercise, smoking cessation , diet
risk factors : blood pressure and blood sugar control
medication : antiplatelets, statin, cilostazole
intervention: if crippling claudication and didn’t improve with medical therapy
angioplasty vs bypass
Q1: How would you approach this case?
Initial Assessment:
Detailed History:
Onset and progression: Sudden or gradual onset, worsening over time, associated symptoms like numbness, weakness, cold sensation.
Back pain history: Type of surgery, post-operative recovery, current back symptoms.
Medical history: Diabetes, smoking, hypertension, hyperlipidemia, family history. Medications: Current medications, including antiplatelet or anticoagulant therapy. Lifestyle factors: Sedentary lifestyle, occupational hazards, smoking.
Physical Examination:
Lower limb: Pulses (femoral, popliteal, dorsalis pedis, posterior tibial), skin color, temperature, capillary refill time, trophic changes. Neurological examination: Sensory and motor function, reflexes. Cardiovascular examination: Heart rate, blood pressure, heart sounds, murmurs. Abdominal examination: Aortic bruits, abdominal tenderness.
Investigations:
ABI: Assess peripheral arterial disease.
Doppler ultrasound: To visualize blood flow in the arteries and veins. Angiography: To visualize the arterial anatomy and identify the location of stenosis or occlusion.
Addressing the Specific Case:
To what degree do you agree with the previous diagnosis of neurogenic claudication?
Given the normal leg raising test, absent distal pulses, and abnormal ABI, a vascular etiology, specifically peripheral arterial disease (PAD), is more likely than neurogenic claudication.
Do you need any further investigations?
Angiography: To confirm the diagnosis and identify the location and severity of arterial disease.
What would be your treatment plan?
Risk factor modification: Smoking cessation, diabetes control, blood pressure control, lipid-lowering therapy. Medical therapy: Antiplatelet therapy (e.g., aspirin, clopidogrel) to reduce the risk of cardiovascular events. Interventional therapy: Percutaneous interventions like angioplasty and stenting to improve blood flow. Surgical revascularization: For severe or complex arterial disease.
How would you approach the patient in terms of patient education regarding her condition and the set expectation for her prognosis?
Explain the condition: Clearly explain PAD, its causes, and symptoms. Treatment options: Discuss the benefits and limitations of medical, interventional, and surgical treatments. Lifestyle modifications: Emphasize the importance of smoking cessation, diabetes control, regular exercise, and a healthy diet. Prognosis: Explain that PAD is a chronic condition, but with proper management, symptoms can be improved, and the risk of cardiovascular events can be reduced.
Follow-up: Regular follow-up visits to monitor the condition, adjust treatment as needed, and address any concerns.
One Year Later with Non-Healing Toe Ulcer:
How would you approach this?
A non-healing toe ulcer in a patient with PAD is a serious complication and requires prompt intervention:
Assess the ulcer: Wound bed preparation, infection control, and debridement. Vascular assessment: Repeat ABI and c.t angiography to assess the severity of arterial disease. Interventional or surgical revascularization: To improve blood flow to the foot. In form of endovascular or open surgery
Wound care: Specialized wound care techniques, including negative pressure wound therapy.
Antibiotic therapy: If infection is present
Thanks for your answer, very good patient education approach, regarding 1rst part of the case how would you justify this answer (Angiography: To confirm the diagnosis)
In part 2 (would you consider debridement of the wound before revascularisation?)
A1:
History including past medical history DM,HTN, IHD, AF and dyslipidemia. Present history regarding the main complaint onset course and duration along with aggravating and factors that relieve the leg pain such as leg dependency off the bed. Family history of any vascular disease as long as social history such as smoking and alcohol intake
Examination including general and local INSPECTION for color and ischemic changes of the skin with loss of hair. PALPATIONin the form of Peripheral pulsation in both UL and LL bilaterally and predict the site of the lesion . straight raising test to differentiate bw vascular and spinal claudications. ABPI measurements can give us a clue to the degree of ischemia less than 0.4 for severe ischemia
Examinasion for the probability of venous disease
Examination of the nervous system motor and sensory
Investigation
LABORATORY blood tests for cholesterol CBC KFT
IMAGING
in the form of echocardiogram ECG and Duplex non invasive technique
CTA mainly for aorto iliac and femoro pop segments but not conclusive in tibials for which MRA is prefered specifically in case of renal impairment
Diagnostic angiography is the gold standard but invasive procedure
TREATMENT
Management of risk factors smoking cessation control bl pr DM diet
Vascular lesion
Chronic ischemia consider medical ttt anti platelet statins and vasodilators along with exercise program
CLTI surgical or endovascular intervention
ALI surgical or endovascular such as thrombolysis CDT or mechanical and aspiration thrombectomy
can you just explain in a simple way which investigation would you do for this patient?
History talking about spins surgery and post operative surgery
Risk factors dm HT smocking
Relevant family history
Pain assessment and analysis
Examination
Straight leg raising tests for assessment of neurological assessment
Pulse assessment+ABI assessment
To exclude presence of pad
In case of good ABI and presence of pulse
Referral to orthopaedic surgery
In cases of pad
First if PT with none disabling claudication
Routine lab CBC urea creat lipid profile
Best medical ttt by risk factors contro+muscular exercise l+statins+anti platelets+cilostazol
If disabling claudication
Duplex us assessment+best medical ttt+intervention if no improvement
If cli best medical ttt+ CTA+intervention according to results PTA Vs bypass
Thanks for your answer. Could you please expand of patient education that you will provide for your patient?
Patient education
First about risk factors and other bed affection and effect of risk factors control on course and progrss of the disease
Second about disease progress and prognosis and available ttt modalities and expected results
I will analysia pain complain
When did it start exactly
Characteristics if dull or sharp
Relefing or aggravating things
Site exactly
Radiate any where
Onset if start gradually or sudden
About distance before feeling pain
If there is pain increase in cold whether?
Color changes of rt ll
Any wounds
Pain in his calf or swelling
Any history of trauma
If he had medical history
About previous surgery
Special hapits like smoking or alcohol
About exercise
Taking medications
And
I will assess his pulse and do ABI
And feeling pulse
I will do burgers test
And I will order
Cbc
Renal function
Lipid profile
Arterial duplex
Thanks for pragmatic approach on history taking.
Could you expand how will the arterial duplex will help you to manage this patient?
Duplex will provide me information about arterial wave (triphasic or bi or mono)
If there is stenosis or occlusion
If there is distal open lune as (presence of distal run off)
Thanks Ahmed. After you get all these information. How would this change your management? What is the clinical benefit for the patient in return for the cost of the scans?
I agree
This not acute in case of absent pulse from history
And clinical examination would be efficient to have plan
And in case of chronicity
no signs of CLTI
So we won’t go for any soon intervention
….
I need to rest my mind system for pt survey
Q5: now the patient came with a new symptom (unhealed foot ulcer)
now i will re-categorize him to the next level “CLTI”, and will now go for the next line of investigations which is CTA to delineate the arterial tree and localize the culprit lesion and plan for the revascularization strategy.
Thanks Remon for organised answer.
How would you define disabling claudication?
How arterial duplex would help you managing this patient?
could you expand on the importance of follow up? what benefit you will offer for the patient in this follow up?
Q4: i will discuss with the patient about
Q3: treatment plan:
firstly i will categorize this patient; CLTI or not.
according to previous data he is just claudicant.
treatment will be according to the severity of his symptoms and if such claudications are disabling.
if not disabling claudications, i will offer him BMT and no intervention.
Q2: further investigations:
Q1: I disagree with the previous diagnosis.
my approach to diagnosis is that this patient complains of claudication pain. this could be one of 3:
from the given data in history: patient has 2 risk factors for atherosclerosis (DM, smoker).
also his claudication pain improves with rest,
and on examination there is absent distal pulse.
so it is mostly arterial claudication.