Approaching patient with ischemic symptoms in the lower limb Answers of the patient with limb pain and ulcer ( model answer) The limb is ischaemic with tissue loss secondary to arterial insufficiency. The most common cause of ischaemia is atherosclerosis. This patient’s angiogram revealing stenosis in the femoral artery at the adductor canal (arrow).. Multiple small collaterals are seen also. The investigations should include: • ankle–brachial pressure index: this is related to the severity of symptoms but may be inaccurate in diabetic patients: • 1.0: normal • 0.5–0.9: claudication • 0.4: rest pain • 0.2: risk of limb loss • blood tests including full blood count, urea and electrolytes, glucose • electrocardiogram • angiography: Computerized tomography and magnetic resonance angiography are alternative imaging modalities. It is important to distinguish arterial from venous ulceration, as use of compression to treat the former type of ulcer is contraindicated. Patients with tissue loss require intervention. Short, single stenoses in the vessels above the inguinal ligament are amenable to angio- plasty. Below the inguinal ligament the results are not as good and the patient may be best served by bypass surgery. Similarly, multiple stenoses, long stenoses (10 cm) and calcified vessels are best treated with a bypass. Investigations may show that the stenoses are not suitable for either angioplasty or bypass surgery (i.e. absence of a suitable distal vessel to bypass onto), in which case a primary amputation may be the end result. KEY POINTS Medical treatments should not be neglected. These include: • pain control: opiate analgesia • is often required antiplatelet agents: e.g. aspirin, clopidogrel • lipid-lowering agents: e.g. statins • anticoagulants: e.g. low-molecular-weight/unfractionated heparin.
Posted on: Thu, 31 Oct 2013 07:31:44 +0000
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