Case1
•56 years old postman presented to you 6 months ago with right lower limb intermittent claudication at 100 meters, you started him not on any medical treatment, 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.
•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?
Case2
60 Years old male patient ex smoker with previous back surgery. Presented with small ulcer on tip of his 2nd Toe.
•How would you approach this? What information you want to know? And what investigation you would request?
Case 1:
>> further investigations :
Lab : lipid profile, KFTs, HBa1c
imaging : arterial duplex
I may request CTA or MRA according to KFTs and the level of occlusion (only in case I decided to go for intervention)
>> Treatment plan :
life style modifications in the form of risk factors management as in Control DM or HTN if found, and of course Smoking Cessation
most important in this patient is supervised exercise therapy
in addition to medical treatment as anti platelet, statin, and cilostazol
I will consider endovascular intervention only with no improvement on my previous mentioned management
>> approach :
education about that PAD is a progressive vascular condition, and emphasizing the importance of lifestyle modifications
about the expectations :
Realistically I will explain that improvement may take time with conservative management, and also if we need to go for intervention tgis will require lifestyle change from her and good compliance.
______________________________
Case 2:
most important item in approach in this case is the history
the ulcer history regarding duration and pain? as ischmic ulcer painful while neurogenic one typically not
history of neurogenic symptoms, history about back surgery as it might be the cause.
and i will ask about vascular symptoms.
in examination vascular and neurogenic assessment are must.
in investigation i will start with ABPI and if its result points to PAD i will ask for arterial duplex, plain foot x ray
case 1
patients needs duplex us on arterial system of the lower limb with comment on patency, flow , prescence of atherosclerosis or arterial wall thickness
treatment should include life style modifications with smoking cessation, using nicotine replacement and varencline if needed. HTN DM control , supervised exercise program. Antiplatelet and statins are recommended with cilostazol which can improve the claudication distance.
patient can be educated about the chronic nature of the condition and the multfactorial causes. Which emphasizes the significance of compliance to target the factors contributing to his condition. Also pt needs to understand the importance of sustaining modifications to his life style which will help improve claudication.
case 2
history talking including HTN DM and complaint analysis if there was hx of intermittent claudications, prescence of back pain and whether lower limb pain is improved be resting or by changing position or certain posture. Examination including palpation of distal pulses and femoral on both sides, ABPI and toe pressure if needed, location of the ulcer and its morphology if it is over bony prominence or over the tip.. etc . Basic investigation that needs to be ordered is duplex US on the arterial system of lower limb
Case 1
Q1
lab investigation
Hba1c- lipid profile – creatinine albumin ratio – s creat
Radiological : ct angiography
Or MRA if renal function impaired
Q2 starting life style modification ( control DM- htn ) daily walking- healthy food – stoppage of smoking
Start medical ttt ( cilostazole 50 twice- ator 40 mg once – naftidrofuryl 200 3 times )
If failed medical ttt and life style modification for 1 month
Plan for revascularizatio
Q3
– education of life style modification
– education of risk of case and probability of amputation
– education tolerance of medication and its benefit
– explain role and risk of revascularization
Q 4
Ulcer
Size small or large
Shape of edge will circumscribed/ punched out/ under mined/ slooping
Floor : healthy- invaded- necrosis -pyogenic membrane
Base : fixed- mobile – fragile
Margins : ischemic changes- inflammatory changes – trophic changes
Association : bluish discoloration- hair loss // parathesia – anathesia
Q5
Personal h : working status, sibling
Past h : DM- htn _ STDS
Present history : onset , cource, duration , neurological and vascular symptoms associated with ulcer
Surgical hustory : other op
Medication h : pt regular medications
Q6
Duplex arterial
Hba1c – serum creat
Case 2 :
Q1,
Approach through
History
Analysis ulcer (discharge, margin, base,painful or not,is it recurrent or not )
Scoring pain on. Scale from 0 to 10
Pain released with upheal
Is there claudication
Distance patient can walk before tired
Ask about co-morbidities (DM, HTN,…)
Past surgical history (more information about back surgery)
Family history for like vonditions
Special habits (smoking,…)
Q2,
Information about the blood supply, motor function (range of motion) of the foot
Sensation by examminig all lower limb dermatomes
CRT
measuring ABPI
Q3,
Full lab
On base of last pulsating artery and ABPI I would ask for ct or MRI of vessels
MRI to assess if there is osteomylitis or no
Case 1
.
Q1 yes u need further invs
Labs like cbc, Urea, creat
And imaging CTA for ll as CFA on rt side is weak
And if creat and Urea abnormal go with mra
.
Q2
As pt affected with cludictation
So I will plan him for intervention
My be by surgical bypass
Or endo by using balloon and sent
Or use both
And give him tt post intervention like antiplatelts, anticoagulant, stations and life style modification
Cessation of smoking and do exercise
.
Q3
approach through
History
Analysis pain (cludictation)
Agrvating, releasing
Site, radiation
Type of pain
Scoring pain on. Scale from 0 to 10
Pain released with upheal
Is pain same all over the day or fluctuate
Ask about co-morbidities (DM, HTN,…)
Past surgical history
Family history for like vonditions
Special habits (smoking,…)
Then I will explain for the patient that we need some labs to evaluate condition like CBC, HBA1C, UREA, Creat, Lipid profile
On basis of lab results we will choose either CT or MRI to evaluate your blood tubes, that would guide either we would go with endo or open or both.
Case2
60 Years old male patient ex smoker with previous back surgery. Presented with small ulcer on tip of his 2nd Toe.
•How would you approach this? What information you want to know? And what investigation you would request
History duration of ulcer
Pulses examination and ABI assessment to prove or rule out pad
If pad preesnt with good ABI
For Wound care+ best medical ttt
If poor ABI ulcer more than 2 weeks
CTA assessment and management according either PTA Vs surgery+ best medical ttt
Case(1):
-Further investigations:
Labs: CBC, renal functions, lipid profile, coagulation profile.
Imaging: arterial duplex U/S for RT L.L
Invasive: CTA or MRA in case of failed medical treatment.
-Treatment plan:
Start by life style modification and control of risk factors: as cessation of smoking.
Best medical treatment; vasodilators,antiplatelets and statins.
Walking exercise to improve collaterals.
In case of failed improvement of symptoms then plan for revasculariztion procedure.
-I will council the patient and explainto him the nature of IC and importance of life-style modifications and the need for revascularization procedures in case of failed medical treatment and risks of intervention and possibilty of post-operative major amputation.
Prognosis will be better in case of cessation of smoking and reversing the risk factors of PAD.
Case(2):
I will start by history taking, ask about risk factors as smoking, HTN, DM, back surgery, then analysis of the complain and duration of the ulcer.
Then clinical examination by inspection of ulcer, skin, hair, then checking distal pulses, straight leg raise test.
Asking him what posture relieves the pain …. try to rule out neurological cause.
Investigations:
Labs: CBC, HgbA1C, renal functions, electrolytes
imaging: Arterial duplex U/S to check flow volume of blood
Plain X-ray for foot to detect osteomyelitis if present.
Hi Ahmed
Thanks for your answers,
Case one:
Case two:
Case 1
A1 ..For this patient I will ask for Arterial duplex US to confirm my diagnosis of PAOD.
for this patient who complain only from claudication I will postpone CTA only if medical treatment fails and intervention will be the plan
A2 .. since the patient was not on .any treatment regmine I will start his treatment by best medical therapy . In the form of aspocid , statin, risk factors modifications and supervised exercise program. I will adopt medical treatment for 3-6 months and if it fails and since it become to be life limiting claudication I will change my plan for intervention
A3.. I will council the patient clearly about his disease . What is it , what are the symptoms of PAD, how to deal with his complaint (IC) and the progressive nature of the disease . I will advice the patient to change his life style habits with control of risk factors if present . As smoking cessation and blood pressure and blood sugar control.
And regarding prognosis I will tell him that it is a systemic disease of progressive nature and could be easily controlled If he strictly follow the conservative treatment protocol and if it fails . Intervention can improve the symptoms
Case2
A1.. for this patient I will begin by analysis of his complaint as onset , course and duration of the ulcer .
I will ask about history of preceding intermittent claudication or rest pain .
I will ask about risk factors of CLTI . AS DM, HTN , sedentary life and history of dyslipidemia
Cardiac history and medication history is of quite importance
Then I will start by patient examination of .
Peripheral pulsation .
Temperature changes
Inspection of skin condition, nails and skin hair.
Then I will do ABPI
I will ask for
CBC, CRP, X-RAY and Arterial duplex US
Dear Mahmoud,
Thanks for good answer,
Case1: why do you want to do duplex even the ABPI is showing indication of PAD.
very satisfactory answers for Q 2& 3
Case 2:
History taking including medical history DM HTN CKD IHD CVA family history social history smoking and surgical history of vascular op
Analysis of the complaint onset course duration along with increasing and decreasing factors
Examinations of the ABPI pulses SLR test together with ulcer examination any signs of infection charcoat neurological examinations
Investigation
Labs
CBC LIPID PROFILE KFT HbA1c
Imaging
Foot x ray
arterial duplex
MRA
CTA if the lesion is expected to be more proximal or aneurysm is suspected
Thank you Dr Reda, Thank you for really good answer.
Examination showed very good femoral pulsation and nothing distal on the affected side. patient is only hypertensive with no other major comorbidities?
could you please indicate which investigation would you consider and what are your treatment option?
CASE 1
Q1: full history about risk factors like smoking history and diabetes and hypertension and dyslipidemia
i will go for complete blood count and serum creatinine level, lipid profile and HBA1c if he is diabetic
for his the right lower limb i will order arterial duplex and due to the weak femoral pulse on the right lower limb i will go for CTA after that to assess the inflow
Q2: due to he is a postman which means that walking long distance may be crucial for him and now he is presented with Disabling claudication so after CTA i will offer him intervention with either open or endovascular according to his lesions
Q3:the patient has to know that atherosclerosis is a systemic disease and affecting all the vascular beds so we have to work on risk factors modification and smoking cessation and medical treatment with the intervention whatever the type of intervention and the prognosis will be much better with the good control of his risk factors
CASE 2
full history smoking, diabetes, hypertension, dyslipidemia and family history of lower limb ulceration
full examination of his pulsation and the ulcer charactaristics
information about his complaint before doing the back surgery which could be an intermittent claudication due to PAD
will start with duplex assessment of his arterial system after measuring his ABI
Thanks Dr Malik,
great answers, Q2, could you refer to ESVS guidelines and suggest what would be the treatment of choice in TASC A,B lesions in iliac vessel.
primary stenting using self expandable bare metal stent recommendation 1 level of evidence b
Case1
A1: investigations in the form of
Labs: lipid profile KFT HbA1c
Imaging: non ivasive duplex wouldn’t be conclusive regarding his weak femoral pulse indicating proximal lesion so CTA will be preferable or MRA if the patient has elevated renal function
A2: according to his disabling claudication the patient will need intervention in the form of surgery , endovascular or hybrid along with medical ttt and life style and risk factors modification with exercise program
A3: approach through
history smoking disease prev operations family vascular intervention dyslipidemea DM HTN CVA
Symptoms analysis onset duration aggravating factor
Examination ABPI PULSES color temp of foot motor sensory straight leg raising test
Thank you so much Dr Reda, Really to the point answers.
•Do you need any further investigations?
ABI assessment+lab assessment CBC hga1c+ urea creat level+lipid profile
•What would be your treatment plan?
Best medical ttt
By risk factors modification+anti platelets anti dyslipidemic rivaroxipan 2.5 mg+ cilostazol
•How would you approach the patient
in term of patient education regarding her condition and the set expectation for her prognosis?
Education about
Risk of diseases progression
Benefits of risk factors modification
Needs for more invasive investigation like CTA or mra
Need for intervention and type of intervention either surgery or pta
Thanks Dr Abdelraheem, Really good answer for Q1.
Regarding medical treatment, which antiplatelet agent would you use?
Would you consider his symptoms as disabling claudication?
Aspirin+ rivaroxipan 2.5 mg
Yes disabling claudication and best to be treated medically as no need for rushing and if no improvement risk and benefit of PTA vs surgery should be discussed with the patient
Case 1
1 arterial duplex to confirm diagnosis
2 Ttt plan
Control risk factors
Medical ttt as antiplatelet , statin & cliostazol
Exercise therapy
3 I will tell the pt about the diagnosis it’s intermittent claudication due to chronic ischemia , our ttt plan which is conservative and if there’s no improvement after 6 ms we will proceed for intervention
Case 2
1 Full history especially risk factors for PAD & ulcer duration
Full examination especially pulsation , ABPI if needed , ulcer charactresitics and neurological ex
Investigations according to the condition if it’s vascular or neurological
Ttt according to if it’s vascular or neurological
2 plus to what mentioned in 1
I want to know about the back surgery details and if there’s any known deficit sensory or motor after the surgey.
3 if there’s absent distal pulsation >>> arterial duplex
if intact distal pulsation >>> Nerve conduction and velocity
.Hi Mostaa,
Could you please expand on how would nerve conduction studies would help with diagnosis even patient has full normal pulsation?