Claudication - NMS Surgery
Terms in this set (25)
A 52yo M develops a cramp in his LLE after walking 100 yards. When he stops and rests, it resolves over 10 min. What does he most likely have?
What is claudication?
Exercise-induced ischemic pain of the calf
Relieved by rest
What arteries are typically involved in atherosclerotic occlusions of the legs?
Superficial femoral artery
--Typically at the adductor hiatus
May involve aortoiliac arteries too
Your pt with claudication has absent pedal and popliteal pulses, but femoral pulses are present. Where is the occlusion?
Occlusion is in the superficial femoral artery
--Typically at the adductor hiatus
Your pt with claudication has absent pedal, popliteal, and femoral pulses. Where is the occlusion?
Occlusion is in the aortoiliac vessels
--Must be above the femoral artery
Your pt with claudication has absent pedal and popliteal pulses, but femoral pulse is present. What is the next step?
Non-invasive vascular examination
Your pt with claudication has absent pedal and popliteal pulses, but femoral pulses are present. He needs a non-invasive vascular examination. What does this consist of?
Calculate ankle-brachial index (ABI)
Doppler tracing at different levels to detect location of stenosis
What are normal doppler findings in the lower extremity?
Normal Doppler waveform is triphasic
--Rapid systolic flow
--Brief reverse flow secondary to elastic recoil of the vessel
--Prolonged diastolic outflow
Doppler studies in a normal extremity would should triphasic waveforms. What are the typical doppler findings in peripheral vascular insufficiency?
Doppler waveform is biphasic or monophasic
Vessel becomes less compliant due to atherosclerosis
--Reverse flow component is lost
--In severe disease, may be monophasic
Following non-invasive vascular exam, you determine your pt has peripheral vascular disease with claudication. Would you recommend vascular reconstruction?
Depends how much claudication interferes with life
--Most pts: Non-operative therapy
--If pts livelihood depends on limb, operate
Most pts with claudication (but not risk for limb loss) are treated with non-operative management. What does this mean?
--1/3 of pts will improve
--1/3 of pts will stabilize
--1/3 of pts will worsen
--Manage other disorders (HTN, DM)
Most pts with claudication (but not risk for limb loss) are treated with non-operative management. Should these pts get an arteriogram to establish a baseline?
--Arteriogram has risks, and unless surgery is planned has no benefit
Your pt with claudication has absent pedal, popliteal, and femoral pulses. What is the prognosis of this compared with superficial femoral disease?
Aortoiliac disease is more progressive
Aortoiliac disease is usually more progressive than superficial femoral disease. How does this alter management?
Surgery is often considered initially
Your pt with a history of claudication comes in with an ulcer on his big toe. How would you evaluate this pt?
Evaluate if his vascular disease has progressed
--Vascular exam (Doppler, ABI)
Your pt with a history of claudication comes in with an ulcer on his big toe. His ABI is 0.3. What is the next step in management?
Revascularize the limb
--Low blood supply will not allow the ulcer to heal
Your pt with a history of claudication comes in with an ulcer on his big toe. You want to revascularize the limb so his ulcer can heal. What study must be done before revascularization?
--Determine the pts vascular anatomy
--Determine if vascular reconstruction will be successful
What are the two general categories of lower extremity vascular disease (in relation to the femoral artery)?
--Occlusion proximal to femoral (aortoiliac vessels)
--Occlusion distal to femoral (superficial femoral artery)
The arteriogram on your pt shows occlusion of the superficial femoral artery with distal reconstitution. How would you manage this pt?
Saphenous vein graft
--From common femoral to popliteal
--Bypass the occlusion
The arteriogram on your pt shows high grade stenosis of the iliac artery but patency of the lower extremity vessels. How would you manage this pt?
--Aorta to femoral artery
Balloon dilatation also possible
The arteriogram on your pt shows high grade stenosis of the iliac artery and occlusion of the superficial femoral artery. How would you manage this pt?
Treat inflow lesions first
--Bypass graft: aorta to femoral artery
--This might be enough to solve problem
Treat outflow lesions second
--Bypass graft: femoral to popliteal artery
The arteriogram on your pt shows occlusion of the superficial femoral and popliteal arteries with distal reconstitution. How would you manage this pt?
--Make the bypass to the vessel that perfuses all the branches to the foot
The arteriogram on your pt shows multiple obstructions in the upper and distal leg, with only small runoff vessels below the ankle. How would you manage this pt?
This is severe atherosclerotic occlusive disease
--Reconstruction might not be possible
--Primary amputation and rehab is appropriate
Following vascular bypass surgery, what follow-up should be done?
-Ensure graft is open?
-Prevent graft from clotting?
Ensure the graft is patent
--Frequent duplex exams of the graft
Prevent the graft from clotting
Your pt has severe peripheral vascular disease. What is the most likely cause of death in these pts?
Coronary artery disease
--Pts with peripheral disease often have coronary disease as well
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