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

2. 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.

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

4. 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:

5. 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

6. 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

7. What is your Differential Diagnosis?

8. 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

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

10. 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

11. Differential Diagnosis Would you like to update your differential?

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

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

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

15. 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

16. Lab Results, Discussion

17. Interventions at this point?

18. 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

19. What next?

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

21. 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

22. 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

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

24. Angiogram

25. Angiogram

26. Angiogram

27. Angiogram

28. Angiogram

29. Angiogram

30. Angiogram

31. Angiogram
How would you describe the findings?

32. What would you do now?

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

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

35. 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%

36. QUESTIONS ??????

37. 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

38. Acknowledgment
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