ABC of arterial and venous disease: Chronic lower limb ischaemia

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Abstract
Intermittent claudication History and examination A history of muscular, cramp-like pain on walking that is rapidly relieved by resting, together with absent pulses, strongly supports the diagnosis of intermittent claudication. Disease of the superficial femoral artery in the thigh results in absent popliteal and foot pulses and often causes calf claudication. Disease of the aorta or iliac artery results in a weak or absent femoral pulse, often associated with a femoral bruit. Disease at this level may cause calf, thigh, or buttock claudication. View larger version: In this window In a new window Method of palpating dorsalis pedis (left) and posterior tibial (right) pulses. Examine pulses from the foot of the bed, keeping the fingers flat for the dorsalis pedis and using the fingertips for the posterior tibial, while applying counterpressure with the thumb View larger version: In this window In a new window Method of palpating femoral pulse in skin crease of groin. Counterpressure on the lower abdomen pushes the skin crease towards the inguinal ligament and reduces the risk of missing the pulse View larger version: In this window In a new window Method of palpating popliteal artery with patient's knee slightly flexed. Use thumbs to apply counterpressure while palpating the artery, which lies deep in popliteal fossa, with fingers The dorsalis pedis artery lies superficially on the dorsum of the foot, although its position varies considerably. The posterior tibial artery lies deeper behind the medial malleolus. Many healthy people have only one foot pulse. The popliteal pulse can be difficult to palpate in muscular patients. A prominent popliteal pulse suggests the possibility of a popliteal aneurysm. Differential diagnosis The pain of nerve root compression can be mistaken for vascular claudication. A careful history can usually distinguish nerve root compression, especially sciatica due to compression of the lumbosacral root. However, compression of the cauda equina due to spinal stenosis can be more difficult to diagnose. This condition usually causes pain that radiates down both legs. Although the pain is made worse by walking, it also comes on after prolonged standing and is not rapidly relieved by rest, unlike vascular claudication. View larger version: In this window In a new window Algorithm for investigation of suspected intermittent claudication Investigation There are many causes of leg pain that can occur in the presence of asymptomatic peripheral vascular disease. Therefore, the absence of pulses does not necessarily imply a causal link. Furthermore, the presence of pulses at rest does not exclude symptomatic peripheral vascular disease. A good history together with an ankle brachial systolic pressure index of less than 0.9 confirms the diagnosis. View larger version: In this window In a new window Algorithm for treatment of intermittent claudication Exercise testing provides an objective measurement of walking distance, and highlights other exercise limiting conditions such as arthritis and breathlessness. However, exercise testing takes time, and many patients find it difficult or impossible to walk on a treadmill. Only those with a good history of claudication and normal resting ankle brachial systolic pressure indexes require an exercise test. Duplex ultrasound scanning is useful for delineating the anatomical site of disease in the lower limb. Many hospitals still use arteriography for this purpose or when the results of duplex scanning are equivocal. This invasive and expensive investigation should not be requested unless there is a plan to proceed with revascularisation, if possible. Principles of treatment Intermittent claudication seems a relatively benign condition, although severe claudication may preclude patients from manual work. The risk of generalised vascular disease is probably more important. Patients with claudication have a three times higher risk of death compared with age matched controls. Modification of risk factors is therefore vital to reduce death from myocardial infarction and stroke. All patients should be advised to stop smoking and take regular exercise. They should also be screened for hyperlipidaemia and diabetes. Patients with peripheral vascular disease benefit from regular chiropody, and those with diabetes should attend a foot clinic. Obesity reduces exercise capacity, and losing weight will improve the walking distance. View this table: In this window In a new window Factors which may influence the decision to treat claudication View larger version: In this window In a new window Treadmills can be used for objective measurement of walking distance and for exercise training Drug treatment All patients with peripheral vascular disease benefit from aspirin (75-300 mg/day) because this reduces the risk of cardiovascular events. Patients who are intolerant of aspirin should take dipyridamole (200 mg, twice daily) or clopidogrel (75 mg/day). Naftidrofuryl may improve the walking distance of patients with moderate claudication (less than 500 m), but it is not known if it affects the outcome of the disease. The evidence to support naftidrofuryl is controversial, and patients prescribed it should be reassessed after three to six months. Exercise programmes A recent meta-analysis of 21 supervised exercise programmes showed that training for at least six months, by walking to near maximum pain tolerance, significantly improved pain free and maximum walking distances. The only controlled trial comparing an exercise programme with percutaneous transluminal angioplasty found that exercise was better. Exercise programmes are cheaper than percutaneous transluminal angioplasty or surgery, although long term compliance seems poor. Endovascular techniques The number of percutaneous transluminal angioplasties performed for claudication has risen steeply in recent years. In some situations endovascular techniques have virtually replaced conventional...

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