00:01
Now, whenever I'm faced with a patient
who complains of malperfusion in the lower extremities,
sometimes call claudication or rest pain,
I ask myself some very important questions.
00:13
Number one, how far can the patient walk?
Two, is there pain when the patient wakes up?
And three, are there any ulcers
or signs of malperfusion.
00:25
With the answers to these three
common and important questions,
one can have a very good idea
of the level of the vessel stenosis
and whether anastomosis is even present.
00:39
Let's take a look at some physical findings?
And very importantly, differentiate
claudication versus rest pain.
00:46
In claudication,
pain is usually induced with exercise,
but resolves with rest.
00:51
And this occurs over
approximately two to five minutes
as opposed to rest pain.
00:56
Rest pain usually is in the forefoot and toes
and the pain can be worsened if the
leg is raised or in a recumbent position.
01:03
This make sense.
01:04
In a recumbent and/or raised position,
there's even further decreased flow.
01:10
And sometimes, the pain is
relieved by dangling the foot
or the feet over the bed.
01:15
We alluded to this ankle brachial index,
also called an ABI.
01:20
As you examine the pulses,
very importantly,
check every pulse from the abdominal
aorta down to the femoral system,
popliteal, dorsalis pedis and posterior tibial system.
01:33
How can you objectively identify whether or not
there is a pressure drop gradient
from your brachial to your ankle?
Well, it’s by the angle brachial index.
01:43
An ABI,
or the ratio between systolic
blood pressure in your ankle
and the systolic blood pressure in your arm,
less than 0.4 is highly suggestive of rest pain.
01:55
Remember, ankle brachial index
is extremely sensitive and specific.
01:59
And additional studies are usually
not necessary to simply diagnose
peripheral occlusive arterial disease.
02:05
But remember, imaging may be
useful for surgical planning.
02:12
Unfortunately, routine laboratory
studies are unlikely to be helpful
unless there's some infection going on.
02:18
Whether it's an non-healing
toe or a gangrene,
you may see an infection and an elevated
white blood cell count as a result.
02:29
Let's move on to some
helpful imaging diagnosis.
02:33
Using a duplex, again,
it’s operator dependent.
02:36
It's an ultrasound technology that
introduces no radiation to the patient.
02:41
The duplex has the additional
advantage of giving velocities.
02:44
Recall, velocities are
higher in stenotic regions.
02:49
And with a Doppler or ultrasound,
we can also get some anatomic idea.
02:54
Next, this image shows a
fairly classic CT angiography.
02:59
Arteriograms is the gold standard0
for diagnosis of vascular disease.
03:04
As a multidetector slice CAT scan’s
cross-sectional imaging improves,
CTs are slowly replacing invasive arteriograms.
03:14
Here, highlighted by the circle
as well as the arrow,
this arteriogram shows narrowing
and occlusion in the tibial system.
03:20
If you look further down the extremity,
you notice that there are
some wisps of contrast filling.
03:26
That's called reconstitution and runoff.
03:30
Increasingly,
magnetic resonance imaging
is being used for arterial disease.
03:36
Here, you see a nice depiction of an MRA.
03:39
There appears to be some occlusive
disease in the right lower extremity.
03:44
And lastly,
given all the cross-sectional imaging,
modern technology allows us
to do 3-D reconstructions.
03:51
Here, you see a nice example
of aneurysms just above the knee.
03:55
They’re marked in red.