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Claudication

Claudication. Michael Hong, M.D. Definitions. Claudication - Pain from lower extremity ischemia with exertion (to limp) Critical limb ischemia Rest pain – Pain from lower extremity ischemia at rest Tissue loss – dry or wet gangrene from vascular insufficiency

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Claudication

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  1. Claudication Michael Hong, M.D.

  2. Definitions • Claudication - Pain from lower extremity ischemia with exertion (to limp) • Critical limb ischemia • Rest pain – Pain from lower extremity ischemia at rest • Tissue loss – dry or wet gangrene from vascular insufficiency • Leriche syndrome – diminished femoral pulses, buttock claudication, and atrophy from aorto-iliac occlusion

  3. DDx • Peripheral arterial disease • Acute limb ischemia • 5 P’s: pain, pulselessness, pallor, parasthesia, paralysis • Neuropathy • Joint pain or other musculoskeletal

  4. History • Crampy, burning pain when walking • Consistent or gradually worsening distance • Typically involves muscle groups one level below site of stenosis/obstruction • Relieved with rest • Smoking history, risk factors (DM, CAD, etc) • Walking distance

  5. Physical Exam • Inspection • Shiny, scaly skin • Hair loss, dystrophic toenails • Muscle atrophy • Dependent rubor • Ulceration / Gangrene • Palpation • Femoral, popliteal, DP, PT pulses

  6. Studies • Ankle-brachial index – ABI • Ankle pressure / Highest brachial pressure • Normal 1-1.1 • Claudication ~0.7-0.9 • Rest pain ~0.5 • Tissue loss ~0.3 • Calcification artifact (usu. in DM) ~1.0-1.3 • Arterial duplex ultrasound • Higher velocity in areas of stenosis • Arteriogram

  7. ABI - Measuring

  8. ABI • Triphasic waveform – healthy, normal, due to vessel recoil from pulsatile flow • Upswing and downswing • Biphasic waveform – mildly abnormal • Monophasic waveform – flattened waves, more progressive disease

  9. ABI – Sample Output

  10. Management • Medical management • Walking program • Risk factor control: smoking cessation, aspirin, plavix, statin, beta-blocker, ACE-I/ARB • Cilastazol (Pletal) • Endovascular – angioplasty, stent, atherectomy • For single, short lesions • Open Bypass – vein, graft • For multiple or long segment lesions • Amputation – last resort

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