Week 1 – Case 1
56 years old postman presented to you 6 months ago with right lower limb intermittent claudication at 100 meters, you started him on best medical therapy, exercise and despite his claudication has not improved. and he mentioned it is really affect his work and they might move hm to desk job which he is not keen for.
on Examination he has weak right femoral pulse with absent distal pulses, calf hair loss and capillary refill of 4 seconds
ABPI of 0.6 on the right side and 0.9 on the left.
what will be your next step of management?
I will order arterial duplex at both LL as initial investigation
Then if I plan for intervention:-
I will order CTA and discuss with the patient the plan for ttt (angioplasty or surgical)
Also, order full labs, ECG, echo, chest X-ray
Refer him to anthologist for fitness
I will request full bloods including renal function and CTA abdominal Aorta and both LL, then decide accordingly
Full labs
Duplex CTA
Assessment of pt functional capacity and fitness.
Discus with the pt possible options for revasculraization as the pt is indicated for that and the complication of each procedure.
According to anatomy, fitness, and pt preference either endo or open surgery intervention
Revascularisation will be considered .
first we will detrmine the anatomy of lesion via imaging : Arterial duplex & CTA or MRA
and patient will be candidate for intervention acoording to lesion site .
intervention options acoording to patients fitness for surgery & other risk factors: open surgical intervention,endovascular &Hyprid treatment.
then best medical treatment , Risk modification & exercise therapy will continue post intervention.
I will make sure that is following the best medical therapy
which include risk factor modification, exercise therapy and pharmacological drugs.
Then I will ask for arterial duplex of both lower limbs with comment on Peak systolic velocity of the whole arterial tree.
Then I will ask for CTA on arterial system of both lower limbs if intervention is planned.
Next step in this setting of failure of symptom improvement despite BMT and excercise sould plbe to plan intervention, weak femoral pulse would indicate iliac / aorto-iliac disease, i would order a CTA/MRA , pre-op labs and prepare for revascularization, be it Endo or Open as lesion would dictate.
Based on the information given, the patient has life limiting claudication which clinically obvious it is arterial in origin. As I am planning for intervention, I will request full bloods including renal function and CTA abdominal Aorta and both LL, then decide accordingly.
The patient has functionally limiting claudication despite adherence to medical ttt & exercise for the longest recommended period of 3-6 months, So..
– Revascularization is a reasonable next step.
– Ask for further imaging (Duplex/CTA/MRA/DSA) according to patient’s renal function and available resources. The patient has weak RT femoral pulse so Aorto-iliac lesion is suspected.
– Peri-operative risk assessment to know where we stand regarding patient fitness if we are going to consider various options (open, endo, hybrid).
Full vascular examination already done
Full labs
Duplex
Cta