00:00
Let's talk about the diagnosis. The diagnosis,
again, is usually by history, as we talked
about in the basic series. If the patient
has no symptoms—doesn't have claudication—you
may not detect it unless you were to do some
noninvasive tests, such as ultrasound, to
show that there's a lot of atherosclerosis
already developing. Two factors are important
for making the diagnosis: first of all, classification
of definite intermittent claudication or an
atypical form of intermittent claudication.
And the University of Edinburgh in Scotland
has created a very excellent questionnaire
that's often used by doctors who do vascular
medicine, peripheral vascular disease, and
it's pretty accurate in predicting, from the
patient's responses, whether there's atherosclerosis
in the peripheral arteries that are causing
symptoms. We've already talked about the ankle–brachial
index blood pressure, where one takes blood
pressure in the arm and the leg, and when
there's decreased pressure in the leg compared
to the arm, that tells you that there's obstruction
to blood flow to the leg. It's a very simple
noninvasive test done in the office all the
time.
01:19
Here's some of the questions from the Edinburgh
Questionnaire. You can see the first question:
"Do you get pain or discomfort in your legs
when you walk?" And if you said yes, "Does
the pain ever begin when you're standing still
or sitting?" If the answer "The pain is there
all the time," it's usually not intermittent
claudication. And it's particularly brought
on if you walk uphill or in a hurry, as you
see in question number 3. Continuing with
the Edinburgh Questionnaire, it says, "Do
you get pain when you walk at an ordinary
pace on level ground?" If you only get it
when you're climbing a hill, that's less severe
than if you get it when you're walking on
level ground. It usually means more severe
atherosclerosis if you get it walking on level
ground. And then, of course, "Does the pain
go away when you stand still?" And, of course,
"Where do you get it?" You should get it in
the calf or the buttock when it's related
to poor blood flow to those muscles. So you
can see how the questionnaire really reflects
what we talked about in the basic series.
02:23
A good history... This directs a good history,
tells you something about the likelihood that
the patient has atherosclerotic peripheral
vascular disease. We already talked about
the ankle–brachial index also. It's determined
with a small Doppler device for finding the
brachial artery and for finding the two foot
arteries: the posterior tibial artery and
the dorsalis pedis artery. And then use the
blood pressure cuff technique to measure the
blood pressure in the leg and in the arm.
It should be about normal or even a little
higher in the leg. When it's below the arm
level in the leg, then that is a positive
for obstruction—almost always atherosclerotic.
And the greater the difference—the more
the blood pressure is decreased in the leg
or in the foot—then the greater is the obstruction.
03:18
We can actually tell Does the patient have
mild arterial disease, moderate arterial disease,
or severe arterial disease? We can also do,
as we've talked about before, ultrasound,
in which we actually can see obstruction.
Here, you can see, the red is flow. And you
can see, suddenly the flow ceases. And in
the next picture, the blood vessel is open
and empty. And this is because no flow is
detected, and the little waveforms at the
bottom—the little triangular forms there—show
you that there's very sluggish blood flow
in that blood vessel. It's a very abnormal
pattern for the Doppler. This is a very easily
done noninvasive test, very commonly done.
Let's talk a little bit about therapy. Well,