General Surgery Rotation

General Surgery: Claudication

Patient will present as → a 65-year-old male presents with a 5-month history of progressively worsening right calf pain upon walking. He describes the pain as a tightening or cramping, and it comes on after walking two blocks. The pain forces him to stop walking and is relieved after he sits down for 10 min. He can then resume walking again. The pain comes on consistently at the same 2-block walking distance each time, unless he walks fast or uphill, in which case he can walk much less. He denies waking up at night with pain in his foot. Past medical history is significant for a 1 pack per day (ppd) smoking habit for 40 years and hypertension. Physical examination demonstrates a moderately obese male. He has normal 2+ femoral pulses bilaterally; nonpalpable (0) popliteal, dorsalis pedis, and posterior tibial pulses on the right side; and diminished (1+) popliteal, dorsalis pedis, and posterior tibial pulses on the left. He is moderately obese, yet both legs appear to be thin. The skin on his lower legs appears thinned out, flaky, and dry, with no hair. His toenails are thickened. There are no ulcers in his feet. Capillary refill is diminished in his right foot at 4 seconds (normal ≤ 2 s). Laboratory values reveal a total cholesterol of 280 mg/dl (normal < 200 mg/ dl), LDL of 160 mg/dl (65–180 mg/dl), and an HDL of 35/mg/dl (>35 mg/dL).

Claudication derives from the Latin word claudicare and means “to limp.” It is caused by a reduction in blood flow to the leg muscles, most commonly by an atherosclerotic plaque.

  • It is not due to a blood clot or embolization. The reduced arterial blood supply cannot meet the metabolic demand of the muscles utilized during walking.

The diagnosis can readily be suspected based on the three-part definition obtained by history:

  • pain in the leg with walking
  • relieved within a few minutes of rest
  • reproducible at the same walking distance each time

Claudication is a symptom of peripheral arterial disease (PAD)

  • PAD most often affects the lower extremities and less commonly the upper extremities and the intestinal and renal arteries.
  • It is usually caused by atherosclerosis.
  • It leads to a gradual slowly developing reduction in blood flow in the extremities (chronic limb ischemia).

Main risk factors for PAD include smoking, diabetes, hypertension, hypercholesterolemia, advanced age, male gender, obesity, sedentary lifestyle, family history of vascular disease, heart attack, and stroke.

PAD causes a progressive loss of blood supply to the leg. The calf muscles atrophy; hair appendages die (hair loss), as do sweat glands (dry scaly skin); the skin thins out (shiny), and ulcers may develop. Capillary refill time becomes prolonged (normal is ≤ 2 s).

Watch Out

Always ask about rest pain, as the presence of rest pain identifies a patient as having limb-threatening ischemia.

PAD is Defined as an ABI < 0.9. The ABI Confirms the Diagnosis of PAD, Gives an Indication of Severity, and is a Useful Tool to Follow Progression

  • Normal ABI 1.2–1.0
  • Mild disease 0.9–0.7
  • Moderate disease 0.7–0.4
  • Severe disease/rest pain <0.4

Angiography is considered the gold standard for diagnosing PAD/PVD

  • A-gram (arteriogram: dye in vessel and x-rays) maps disease and allows for best treatment option (i.e., angioplasty vs. surgical bypass vs. endarterectomy)

Platelet inhibitors: Cilostazol, Aspirin, Clopidogrel

  • Treat lipids - Statins
  • Revascularization with PTA, bypass grafts, stenting
  • Exercise - walking to the point of claudication

***βblockers are contraindicated in isolated PAD – it will worsen claudication!

Treatment options for severe PVD?

  1. Surgical graft bypass
  2. Angioplasty—balloon dilation
  3. Endarterectomy—remove diseased intima and media
  4. Surgical patch angioplasty (place patch over stenosis)

What is a FEM-POP bypass?

FEM-POP GRAFT

Bypass SFA occlusion with a graft from the FEMoral artery to the POPliteal artery

What is a FEM-DISTAL bypass?

FEM-DISTAL

Bypass from the FEMoral artery to a DISTAL artery (peroneal artery, anterior tibial artery, or posterior tibial artery)

 

 

What graft material has the longest patency rate?

  • Autologous vein graft

What is an “in situ” vein graft?

  • The saphenous vein is more or less left in place, all branches are ligated, and the vein valves are broken with a small hook or cut out; a vein can also be used if reversed so that the valves do not cause a problem

General Surgery: Dyspnea on exertion (Prev Lesson)
(Next Lesson) General Surgery: Arterial embolism/thrombosis
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