A 62-year-old man with chronic hypertension presents with pain and fatigue in his legs that occur whenever he walks. The patient says his symptoms have been present for the past 12 months and have progressively worsened. The patient currently has pain and tightness in both calves that develop after walking less than one block but routinely resolve after a short period of rest. His past medical history is significant for hypertension. He smokes approximately one pack of cigarettes per day. On examination, his feet are warm and without lesions. The femoral pulses are normal bilaterally. The popliteal, dorsalis pedis, and posterior tibial pulses are absent bilaterally. Doppler examination of the lower extremities reveals the presence of Doppler signals in both his feet with ankle-brachial indexes (ABIs) showing moderately severe disease: ABI 0.5 on the left, and 0.54 on the right.
What is the most likely diagnosis?
What is the most appropriate next step?
What is the best initial treatment for this patient?
ANSWERS TO CASE 14: Claudication Syndrome
Summary: A 62-year-old nondiabetic man presents with bilateral leg claudication. Based on the physical examination, the patient most likely has bilateral superficial femoral artery (SFA) occlusion.
• Most likely diagnosis: Atherosclerosis with bilateral superficial artery occlusions.
• Next step: Assessment of disability and adequate counseling on the risks and benefits of therapy.
• Best initial treatment: Lifestyle modification with smoking cessation, exercise training, and risk factor control.
ANALYSIS
Objectives
1. Know the differential diagnosis for claudication caused by arterial insufficiency.
2. Be able to recognize the indications for lower extremity revascularization and the benefits and limitations of open surgical and endovascular techniques.
3. Learn the noninvasive modalities available for the evaluation and follow-up of patients with claudication.
Considerations
This patient’s presentation is similar to that of typical vascular disease patients with lower extremity peripheral arterial disease: a history of slowly increasing exertional pain in conjunction with multiple risk factors for atherosclerosis. Lower extremity peripheral vascular occlusive disease (LEPVOD) represents a continuum of regional signs and symptoms of the systemic disease state of atherosclerosis. Intermittent claudication is the most common symptoms associated with LEPVOD. Patients with claudication are at risk for the developing complications related to the lower extremities, as well as coronary and cerebral vascular complications.
Most patients with intermittent claudication can be managed with lifestyle modifications and pharmacologic therapy directed at reducing the patients’ overall atherosclerotic risk factors. Aspirin has not been shown to improve claudication but has been shown to reduce the risk of myocardial infarctions, strokes, and the progression of claudication symptoms. The antiplatelet agent, clopidogrel is more effective than aspirin in the prevention of cardiovascular ischemic events; however, this medication is associated with increased cost and increased bleeding complications. Lipid-lowering medications (statins) have been found highly effective in reducing the risk of major cardiovascular events in patients with peripheral vascular disease.
For patients with more advanced stages of ischemia, interventional treatment for limb salvage becomes the desired goal. The recommended standard of LEPVOD classification can help stratify patients according to their presentation and treatment (Table 14–1). More advanced disease generally implies more anatomic levels with occlusive or stenotic pathology. The patient’s ABIs of 0.5 and 0.54 are consistent with exertional pain.
Table 14–1 • FONTAINE CLASSIFICATION OF LOWER EXTREMITY PERIPHERAL VASCULAR OCCLUSIVE DISEASE
APPROACH TO: Lower Extremity Vascular Disease
DEFINITIONS
LOWER EXTREMITY PERIPHERAL VASCULAR OCCLUSIVE DISEASE: Ischemia in the lower extremities caused by arterial stenosis. Acute ischemia is typically characterized by a sudden onset of pain, pallor, and pulselessness. Chronic arterial ischemia manifests as lower extremity pain with exercise and resolves with rest.
ARTERIAL BYPASS: Surgical procedure in which one artery is connected to another artery with a conduit (such as a saphenous vein or prosthetic material).
ABI: Ratio of Doppler signals of the ankle systolic blood pressure to those of the brachial artery, normally greater than 0.95; intermittent disease correlates with 0.5 to 0.95, and severe disease with less than 0.5.
TASC CLASSIFICATION OF FEMORAL POPLITEAL OCCLUSIVE DISEASE: (1) Type A—single stenosis less than 10 cm in length or single occlusion less than 5 cm. (2) Type B—multiple lesions (each <5 m in length); single or multiple tibial vessel lesions to impede outflow for a distant bypass; heavily calcified occlusion less than 5 cm in length; single popliteal stenosis. (3) Type C—multiple stenosis or occlusions totaling greater than 15 cm; recurrent stenosis or occlusions that need treatment requiring two or more interventions. (4) Type D—chronic total occlusion of common femoral artery (CFA) or SFA (>20 cm or involving the popliteal); chronic occlusion of the popliteal and trifurcation vessels. In general, the outcomes after intervention are better with type A lesions with worsening outcomes from A to D.
CLINICAL APPROACH
Not all patients presenting with effort-related lower extremity pain have vasculogenic claudication; in some cases, neurogenic claudication needs to be differentiated from vasculogenic claudication. Neurogenic claudication can occur in association with lumbar stenosis, which can also produce excruciating lower extremity pain during exertion or positional changes; however, the onset of neurogenic claudication symptoms tends to occur more sporadically and may require positional changes for symptom improvement. Physical examination findings such as skin temperature, capillary refill, and peripheral pulses are useful to help differentiate patients with neurogenic symptoms from those with ischemic symptoms.
An understanding of the arterial circulation helps one to localize the pathology in LEPVOD. Increasing levels of arterial involvement usually suggest a greater need for interventional therapy. One must also keep in mind that patients with LEPVOD have systemic atherosclerosis; thus, there is a higher probability of concomitant coronary artery and carotid artery disease. The other manifestations of atherosclerosis impact long-term survival in patients with LEPVOD. Diabetes is important in LEPVOD, both because of its presence as an independent risk factor and because it can alter the clinical presentation. Neuropathy can confound an impression of ischemic rest pain. Additionally, the susceptibility of a diabetic patient to infection can enhance the risk of tissue loss.
Lifestyle therapy and risk factor modification are essential for all patients with LEPVOD. At a minimum patients should be counseled regarding the increased risk of cardiovascular and cerebral vascular disease–related morbidity associated with LEPVOD, and management for all patients need to include lifestyle modifications such as smoking cessation, exercise therapy, hypertension management, diabetic management and glycemic control, pharmacological therapy to improve lipid profiles, and dietary counseling. Patients with LEPVOD should be placed on antiplatelet therapy. Clinical trial results indicate that aspirin helps delay the progression of LEPVOD symptoms. In a trial of patients with high risk for cardiovascular ischemic events, patients randomized to clopidogrel experienced lower rates of nonfatal strokes, nonfatal MIs, and cardiovascular deaths than those randomized to aspirin. The use of clopidogrel is, however, associated with higher cost and slightly increased rate of treatment-related complications.
Because any surgical or endovascular intervention can cause possible limb- or life-threatening complications, the clinician needs to weigh the risks and benefits of intervention for a patient with claudication differently than for a patient with digital gangrene. The patient with claudication should be severely disabled and not merely inconvenienced before being considered for either endovascular treatment or an arterial bypass. Conversely, the patient with digital gangrene is in a limb-threatening situation, requiring definitive revascularization if the limb is to be salvaged. Tissue loss is a limb-threatening presentation that requires revascularization. True ischemic rest pain with multilevel LEPVOD also requires revascularization for definitive treatment. A patient with claudication with severe lifestyle limitations (such as the loss of a job) may be a candidate for revascularization if the risk profile is not too unfavorable.
All interventional therapy carries a spectrum of risks and benefits. Angioplasty techniques work best for proximal vessels with short, focal, concentric, noncalcified atherosclerotic stenosis. In selective cases, when there is residual gradient or dissection following angioplasty, stent placement may help improve short-term patency. The more unfavorable the lesion is with respect to length, number, location, and morphology, the less successful percutaneous therapy will be. Percutaneous treatment of occlusive disease at the femoropopliteal level is being increasingly utilized as technological advances are being introduced. As a general rule, outright arterial occlusions require bypass to achieve revascularization. More proximal-level bypasses at the aortoiliac level can achieve 90% 5-year patency, whereas distal femoral-tibial bypasses can achieve less than 65% 5-year patency.
COMPREHENSION QUESTIONS
14.1 A 57-year-old man who works as a deliveryman is able to walk only 40 yards before stopping because of right calf and thigh cramping. He is worried that he will lose his job. He is a diabetic and takes an oral hypoglycemic agent, a long-acting β-blocker, and a statin-class lipid-lowering agent. He smokes one pack of cigarettes a day. He has normal right leg pulses but no pulses in the left groin and leg. Which of the following is the most likely site of arterial occlusion?
A. His left aortoiliac system
B. His left SFA
C. His right SFA
D. His left internal carotid artery
E. Infrarenal aorta
14.2 The patient described in Question 14.1 is managed medically. He returns after 8 months with continued calf pain, as well as nonhealing ulcers between his left third and fourth toes. His pulse examination remains unchanged. Which of the following arteries is most likely to be additionally involved?
A. An occlusion in his left internal iliac artery
B. An occlusion in his left SFA
C. An occlusion in his right SFA
D. An occlusion in his right aortoiliac artery
E. Infrarenal aorta
14.3 A patient has the symptoms and ulcers described previously, as well as documented left iliac artery occlusion for the entire left external iliac artery and full-length occlusion of his left SFA with reconstitution of his popliteal artery just below the adductor hiatus. Which of the following is the most appropriate treatment?
A. Lifestyle counseling and risk factor control
B. Smoking cessation
C. A femoral–femoral bypass from the left leg to the right leg
D. A femoral popliteal bypass with a reversed saphenous vein if available
E. All of the above
14.4 An 82-year-old woman with history of severe dementia and left cerebrovascular accident (CVA) is noted to have a gangrenous toe and an erythematous left foot. She is severely debilitated by her dementia and CVA and is bed-bound. Her physical examination reveals normal temperature, normal femoral pulses, diminished left popliteal pulse, and nonpalpable left pedal pulses. Her right lower extremity vascular examination reveals normal femoral pulse and diminished popliteal and pedal pulses. Her left great toe and second toe have dark eschars at the tip with surrounding erythema extending to the mid-foot. Which of the following is the most appropriate treatment option?
A. Obtain an angiogram of the aorta and left lower extremity to identify the areas of occlusion and treat the blockage with angioplasty and stent placement. After blood flow is restored to the foot, proceed with toe amputation and wound care.
B. Obtain an angiogram of the aorta and left lower extremity, followed by an arterial bypass operation to restore flow to the lower extremity. After blood flow is restored to the foot, proceed with toe amputation and wound care.
C. Initiate systemic heparin therapy.
D. Perform left below-the-knee amputation.
E. Wound care and long-term antibiotic therapy.
14.5 A 57-year-old man presents with acute onset of right foot pain. He states that he had been in his usual state of health until 6 hours ago, when he developed sudden onset of right foot and leg pain. Associated with the pain, the patient has noted the onset of numbness in his right toes. His past medical history is significant for hypertension. Physical examination reveals irregular pulse rate of 120 beats/min, blood pressure of 130/82 mm Hg, and respiratory rate of 24 breaths/min. His rhythm on the cardiac monitor shows irregularly, irregular rate without the presence of p waves. His right lower extremity has a bluish discoloration and is cool to the touch below the mid-thigh. His aortic pulse is normal, his right femoral pulse is normal, and the right popliteal and pedal pulses are absent. The femoral, popliteal, and pedal pulses are normal on the left. Which of the following is the most appropriate management option for this patient?
A. Systemic heparinization, right femoral artery thrombectomy
B. Systemic heparinization, angiography, and placement of right SFA stent
C. Systemic heparinization
D. Systemic thrombolytic therapy
E. Right femoral-popliteal artery bypass
ANSWERS
14.1 A. His symptoms imply occlusive disease above the common femoral level, confirmed by the absence of a femoral pulse.
14.2 B. When patients with arterial occlusive disease progress from claudication to tissue loss, multilevel disease is usually present. There is likely to be disease in both the aortoiliac and superficial femoral arteries.
14.3 E. All patients require lifestyle modification, but the patient in question needs a complete multilevel revascularization to prevent limb loss.
14.4 D. Left below-the-knee amputation may be the most appropriate treatment for this elderly, nonambulatory patient with artery occlusion at the femoral artery level. Given the ischemic changes in the left first and second toes, it is highly probable that the patient also has occlusive disease in the tibial arteries as well. Revascularization of the lower extremities is generally not indicated in non-ambulatory patients, and given the evidence of soft tissue infection of the foot, an amputation may be the best option for this patient at this time. Antibiotics alone are generally insufficient for the treatment of soft tissue infections associated with tissue ischemia.
14.5 D. This patient’s acute onset of symptoms and the presence of normal vascular examination in the left lower extremity are highly suggestive of a recent embolic event leading to occlusion of the right SFA. It is important to initiate heparin therapy to prevent the propagation of thrombus in the right lower extremity; at the same time, because the process has been in place for several hours and the patient has clear signs of ischemia, additional vascular imaging may actually delay treatment. An additional procedure to consider in this individual following reestablishment of blood flow is right lower leg fasciotomy to prevent the development of compartment syndrome. The patient may be best served by early operative thrombectomy. In some patients with acute embolic events and no significant ischemia, arteriography with intra-arterial delivery of thrombolytics may be indicated. Operative bypass grafting is generally not indicated for patients with acute arterial insufficiency related to embolic processes.
CLINICAL PEARLS
Pulses are diminished distal to an arterial stenosis and are absent distal to an occluded artery.
Claudication is extremely reproducible, with the same exertional load producing the same symptom complex.
Rest pain is better called “metatarsalgia” to understand where the pain should be, making it different from pain in a foot with diabetic neuropathy.
REFERENCES
Brant-Zawadzki, Kent KC. Femoropopliteal occlusive disease. In: Cameron JL, Cameron AM, eds. Current Surgical Therapy. 10th ed. Philadelphia, PA: Mosby Elsevier; 2011:779-782.
Lin PH, Panagiotis K, Bechara C, Cagiannos C, Huynh TT, Chen CJ. Arterial disease. In: Brunicardi FC, Andersen DK, Billiar TR, et al, eds. Schwartz’s Principles of Surgery. 9th ed. New York, NY: McGraw-Hill; 2010:701-775.
Taylor SM. Treatment of vasculogenic claudication. In: Cameron JL, Cameron AM, eds. Current Surgical Therapy. 10th ed. Philadelphia, PA: Mosby Elsevier; 2011:799-803.