Assignment: Peripheral Vascular Disease Case Studies

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Assignment: Peripheral Vascular Disease Case Studies

Assignment: Peripheral Vascular Disease Case Studies

A 52-year-old man complained of pain and cramping in his right calf caused by walking two

blocks. The pain was relieved with cessation of activity. The pain had been increasing in

frequency and intensity. Physical examination findings were essentially normal except for

decreased hair on the right leg. The patient’s popliteal, dorsalis pedis, and posterior tibial

pulses were markedly decreased compared with those of his left leg.

Studies Results

Routine laboratory work Within normal limits (WNL)

Doppler ultrasound systolic pressures Femoral: 130 mm Hg; popliteal: 90 mm Hg;

posterior tibial: 88 mm Hg; dorsalis pedis: 88

mm Hg (normal: same as brachial systolic

blood pressure)

Arterial plethysmography Decreased amplitude of distal femoral, popliteal,

dorsalis pedis, and posterior tibial pulse waves

Femoral arteriography of right leg Obstruction of the femoral artery at the midthigh


Arterial duplex scan Apparent arterial obstruction in the superficial

femoral artery

Diagnostic Analysis

With the clinical picture of classic intermittent claudication, the noninvasive Doppler and

plethysmographic arterial vascular study merely documented the presence and location of the

arterial occlusion in the proximal femoral artery. Most vascular surgeons prefer arteriography

to document the location of the vascular occlusion. The patient underwent a bypass from the

proximal femoral artery to the popliteal artery. After surgery he was asymptomatic.

Critical Thinking Questions

1. What was the cause of this patient’s pain and cramping? 2. Why was there decreased hair on the patient’s right leg? 3. What would be the strategic physical assessments after surgery to determine the

adequacy of the patient’s circulation?

4. What would be the treatment of intermittent Claudication for non-occlusion?

Case 1: Peripheral Arterial Disease That Is Getting Worse 
Despite Medical Intervention,
65-year-old man was admitted to the clinic after experiencing deterioration of acute left calf pain and decrease in activity tolerance as result of the pain. 
The patient reported occasional left calf pain for three months and denied any injuries, back pain, fever, or limb weakness. 
The medical history, on the other hand, was significant for hyperlipidemia. 
He was former smoker who had quit months prior; nonetheless, he had been smoking pack of cigarettes day for the previous 40 years. 
The patient denied drinking or using recreational drugs. 
Low-dose aspirin and high-intensity atorvastatin were his meds. 
Vital signs were normal on physical examination. 
The BMI was 28 kg/m2 (body mass index). 
Femoral pulses were reduced on both sides. 
Pulses in the popliteal, right dorsalis pedis, and right posterior tibialis were all weak. 
Pulses in the left dorsalis pedis and posterior tibialis could not be felt. 
The results of the cardiac check were normal. 
The physical examination was otherwise ordinary. 
On the left, the ankle-brachial index was 0.67, while on the right, it was 0.91. 
He had been involved in supervised exercise program for three months, but despite strict devotion to the program, the patient’s symptoms worsened. 
How would you handle this situation?


Review of the Situation


Despite initial medical therapy, patient with increasing peripheral arterial disease (PAD) is depicted in this scenario. 
Progressive PAD is characterized by progressive decrease in exercise tolerance due to worsening left leg pain and nonpalpable dorsalis pedis and posterior tibialis pulse on the left side on physical examination. 
The patient is already receiving basic medical treatment for PAD, which includes quitting smoking, taking aspirin, taking high-intensity statins, and participating in supervised exercise program.


Discussion of the Case


The aortic bifurcation and arteries of the lower limbs, such as the iliac, femoral, popliteal, and tibial arteries, are most typically narrowed in PAD. 
The most common cause is atherosclerosis. 
Smoking (current or previous), diabetes mellitus, and advancing age are all risk factors for PAD. 
Ischemic events, such as myocardial infarction, stroke, and cardiovascular mortality, are more common in patients with PAD. 
Patients with atypical limb symptoms (eg, leg weakness, paresthesia), exertional leg discomfort, and/or nonhealing ulcers who have atherosclerotic risk factors (smoking, diabetes, hypertension, dyslipidemia, and advanced age) should have their ankle-brachial index (ABI) measured first.


Symptoms in the Clinic


Because lower extremity PAD is characterized by an abnormal ABI value rather than symptoms, there is wide range of clinical presentations. 
Patients may experience intermittent claudication (exertional leg pain relieved by rest), unusual exertional leg pain, rest pain, nonhealing wounds, ischemic ulcers, or gangrene.


The following is the ABI interpretation:


Severe PAD (ABI 0.00 to 0.40)


Mild to moderate PAD with an ABI of 0.41 to 0.90.


ABI 0.91 to 0.99: PAD on the edge


ABI 1.00-1.40: Average


Noncompressible (ABI >1.40)
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