Assistant Professor of Surgery Medical College of Wisconsin Left Leg Pain Brian Lewis M.D. Assistant Professor of Surgery Medical College of Wisconsin

Ms. Doe Ms. Doe is a 55-year-old woman, c/o progressive left leg pain. She is referred by her PMD to clinic today for evaluation of left leg pain. The right leg gives her no trouble.

What other points of the history do you want to know?

History, Ms. Doe Consider the following: Associated signs/symptoms Pertinent PMH ROS MEDS Relevant Family Hx. Relevant Social Hx. Characterization of Symptoms: Temporal sequence Alleviating / Exacerbating factors:

History, Ms. Doe Characterization of symptoms Temporal sequence Pain occurs in left calf with walking, worsening over time. Feels like a “cramp”. Limits her ability to play with her grandkids. Temporal sequence Only occurs with walking Reproducible at the same distance Alleviating / Exacerbating factors Worse with walking especially up hill or stairs Goes away when she stops

History, Ms. Doe Associated signs/symptoms: Pertinent PMH: No pain in foot when in bed, though both feet tend to be “numb” No wounds on feet Pertinent PMH: ROS: HTN, IDDM, Hyperlipidemia, no hx of DVT/clotting disorders MEDS: Insulin, Amitryptiline, Atorvostatin, Lisinopril, Neurontin Relevant Family Hx. Positive for CAD, Diabetes Relevant Social Hx. Smokes cigarettes ½ ppd for 40 years

What is your Differential Diagnosis?

Differential Diagnosis Based on History and Presentation Muscle strain Dehydration Drug reaction – statins Tendonitis Deep venous thrombosis Claudication Arthritis Varicose veins Malignancy Sciatic nerve pain

What specifically would you look for? Physical Examination What specifically would you look for?

Physical Examination, Ms. Doe Vital Signs: T 98.6° F, P 82, BP 173/81, RR 16 Appearance: Healthy, pleasant, non distressed Relevant Exam findings for a problem focused assessment HEENT: normal, no bruits Pulses: normal radial, femoral, carotid bilaterally; absent popliteal, DP and PT pulses bilaterally Chest: clear bilaterally Neuromuscular: neuropathy in both feet CV: RRR, no murmurs Skin/Soft Tissue: skin shiny on bilateral legs, no wounds, legs non-tender to palpation Abd: Soft, nontender, no masses Remaining Examination findings non-contributory

Differential Diagnosis Would you like to update your differential?

Studies (Labs, X-rays etc.) What would you obtain?

Studies, Ms. Doe Ankle-brachial indices Toe Pressures Right: 0.98 Left: Incompressible Toe Pressures Right: 60 Left: <20

ABI Can anyone describe how ankle brachial indices are performed? What represents normal range? Abnormal? What conditions might falsely elevate the number?

Lab Studies ordered, Ms. Doe These were obtained by PMD 6 weeks ago CBC: Within normal limits LFT’s PT/PTT Electrolytes Urinalysis Lipid Panel Hb A1C 7.8

Lab Results, Discussion

Interventions at this point?

How would you manage this patient? Risk factor control BP control Lower lipids/cholesterol Blood sugar control Smoking cessation β-blockers ASA Exercise program Medications Pentoxifylline Cilostazol

What next?

Next Steps How would you schedule follow-up? Any studies at time of follow-up?

Now pain when she walks only a few steps Ms. Doe calls the office 15 months later complaining of worsening symptoms in left leg. Now pain when she walks only a few steps Now has an open wound on the left first toe States the wound has been present for weeks and is only getting worse

Physical Examination PE is unchanged with exception that there is a swollen left first toe with an open 1cm x 1cm necrotic based wound on the medial aspect The toe is extremely tender There is no drainage from the wound

What studies would you obtain? Ankle-brachial indices Right: 0.98 Left: Incompressible Toe Pressures Right: 60 Left: <20 Anything else ?

Angiogram

Angiogram

Angiogram

Angiogram

Angiogram

Angiogram

Angiogram

Angiogram How would you describe the findings?

What would you do now?

Management Options Observe Surgery Endovascular management What workup would be required? Endovascular management What are some strengths and limitations of the various options?

Post op Management Discuss routine post op Discuss most common complications Mention any rare findings

Discussion Additional teaching points Disease process Claudication 1% - 2% of population <50 yo Up to 5% of population 50 – 70 yo Up to 10% greater then 70 yo At 10 years only 25% have symptomatic disease progression Limb-threatening ischemia Develops in approximately 1 of every 100 claudicators Obtaining consultants High incidence of CAD associated with PVD Approximate percent with no or mild/mod CAD 40% Approximate percent with advanced or severe CAD 60%

QUESTIONS ??????

Summary Intervention for infra-inguinal vascular disease is most often reserved for ? Rest pain Tissue loss Fix in-flow first Below the inguinal level vein is typically the preferred conduit The role for endovascular management is evolving Vascular disease in a single territory is often a marker for generalized vascular disease

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