Case Presentations in Arterial Disease PDF
Preview Case Presentations in Arterial Disease
Titles in the serìes Case Presentations in Arterial Disease Case Presentations in Clinical Geriatric Medicine Case Presentations in Endocrinology and Diabetes Case Presentations in Gastrointestinal Disease Case Presentations in General Surgery Case Presentations in Heart Disease (Second Edition) Case Presentations in Medical Ophthalmology Case Presentations in Neurology Case Presentations in Obstetrics and Gynaecology Case Presentations in Otolaryngology Case Presentations in Paediatrics Case Presentations in Renal Medicine Case Presentations in Respiratory Medicine Titles in preparation Case Presentations in Accident and Emergency Medicine Case Presentations in Anaesthesia and Intensive Care Case Presentations in Urology Case Presentations in Arterial Disease David Bouchier-Hayes, Men, FRCS, FRCSI, FACS Professor of Surgery and Chairman, Department of Surgery, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland Patrick J. Broe, MCh, FRCSI Consultant Surgeon, Beaumont Hospital and Senior Lecturer, Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland Pierce Ä. Grace, Men, FRCSI Lecturer in Surgery, Department of Surgery, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland Denis Mehigan, Men, FRCSI Consultant Vascular Surgeon, St. Vincent's Hospital, Elm Park, Dublin, Ireland U T T E R W O R TH E I N E M A N N Butterworth-Heinemann Ltd Linacre House, Jordan Hill, Oxford OX2 8DP @ PART OF REED INTERNATIONAL BOOKS OXFORD LONDON BOSTON MUNICH NEW DELHI SINGAPORE SYDNEY TOKYO TORONTO WELLINGTON First published 1991 0B utterworth-Heinemann Ltd 1991 All rights reserved. No part of this publication may be reproduced in any material form (including photocopying or storing in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright holder except in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London, England W 1P 9HE. Applications for the copyright holder’s written permission to reproduce any part of this publication should be addressed to the publishers. British Library Cataloguing in Publication Data Case presentations in arterial disease. I. Bouchier-Hayes, D. 617.4 ISBN 0 7506 1355 6 Library of Congress Cataloguing in Publication Data Case presentations in arterial dlseaseDavid Bouchier-Hayes . . . [et al.]. p. cm. Includes index. ISBN 0 7506 1355 6 1. Arteries-Surgery-Case studies. [DNLM 1. Arteries-surgery-case studies. 2. Vascular Disease- diagnosis-case studies. WG 510 C3371 RD598.5.C37 1991 617.4’l Mc20 DNLWDLC for Library of Congress 9 1-29635 CIP Typeset by TecSet Ltd, Walling-ton, Surrey. Printed and bound in Great Britain by Biddles Ltd, Guildford & Qngs Lynn. Preface This is a story book. It was written for undergraduate and postgraduate students preparing for professional examinations. By telling tales it is intended to give the student a flavour of the diversity of arterial disease which will be encountered, not only in examinations, but throughout a professional career. The patients' stories are used as a basis for discussing the problems encoun tered in the presentation, investigation and management of arterial vascular problems. Time and again we emphasize the importance of obtaining an accurate history and performing a thorough clinical examination before rushing off to order the latest and the most expensive investigation. Nobel laureate Herbert Simon has suggested that people fre quently use a personal, learned, subconscious library of patterns when attempting to solve problems. An individual's library of patterns accumulates through years of formal education and practical experience. The mark of the true professional is his rich vocabulary of patterns or, as Simon called them, Old friends'. We hope that the stories presented in this book will become 'old friends' and add to the student's accumulating pattern vocabulary, not only of vascular surgery but of medicine in general. The same format is used for each case presentation. A brief history and the relevant physical findings are presented in each case followed by a comment on the points which might lead one to the correct diagnosis. The rest of the patient's story then unfolds and the merits and demerits of the case and its management are debated in the discussion. This book is not a comprehensive textbook of vascular surgery, but it will be a valuable adjunct to standard texts and an easily read work for revision. We are grateful to Eileen Francis for typing the text. David Bouchier-Hayes PatnckJ. Broe Pierce A Grace Denis Mehigan vu 1 Calf claudication Case 1 Mr J. D., a 67-year-old retired policeman, presented with a 6-month history of intermittent claudication in his left calf. He found that he could walk approximately 200 yards without difficulty but that he then got a severe pain in his calf which prevented him from progressing any further. Resting for a few minutes relieved his pain. Then he could proceed again for another 200 yards. He never got pain at rest, never had pain in bed at night and never had any ulcers on his feet. He had no cardiac or respiratory symptoms and had enjoyed good health all his life. He was not diabetic. He had smoked 20 cigarettes per day for most of his adult life, but admitted to having smoked more since he retired from the police force. On physical examination he appeared to be a fairly fit if slightly overweight man of stated age. His pulse was 85 per min and regular and he was not hypertensive. Examination of chest and abdomen was unremarkable. Both femoral pulses were palpable but no other pulses were palpable on the left side. All pulses except the dorsalis pedis pulse were palpable in the right leg. Elevation of the left leg produced pallor at 70 degrees. The right leg remained pink on elevation to 90 degrees. Comment This is a typical history of intermittent claudication. The patient experiences pain when he walks and the pain is relieved by 1 2 resting. The anatomical site of the arterial disease can be worked out from the symptoms. The pain will always appear in the segment of the body just distal to where the anatomical problem is. Thus iliac artery disease will result in thigh claudication, and femoropopliteal disease will produce calf claudication. Examina tion of the pulses will rapidly confirm the anatomical site of disease. Our patient clearly has femoropopliteal disease because he has calf claudication, a palpable femoral pulse and an absent popliteal pulse. Doppier segmental pressures confirmed the clinical findings in Mr J. D. The ankle/arm pressure ratio was 0.9 in his left leg and 0.7 in his right leg. He was advised strongly to stop smoking and he was commenced on an exercise programme. It was explained to him that if he continued to smoke his disease would progress and ultimately he would lose his leg. He was also commenced on aspirin 300 mg daily. He was reviewed at 3 months when he reported that he could now walk up to one half mile without pain and he had managed to stay off the cigarettes. Discussion Cessation of smoking and taking exercise form the foundation of non-operative treatment of chronic lower limb ischaemia. Most claudicants with an ankle/arm index of greater than 0.6 do not require any further therapy. While the monotonously consistent relationship between smok ing and lower limb ischaemia is recognized by all doctors, only one-third of patients appear to be aware of the connection. Most smokers recognize only an increased risk of lung cancer. Com plete cessation of all tobacco use is the key factor in non-operative therapy of chronic lower limb ischaemia. It is therefore imperative that all patients presenting with claudication be told without equivocation that they must stop smoking. Continued smoking will almost inevitably lead to amputation. Regular walking exercise forms an important part of non- operative therapy for intermittent claudication. A programme of walking exercises results in improved symptoms of claudication in a majority of affected patients. While it has been assumed that the symptomatic improvement with exercise was due to increased 3 collateral circulation, a number of studies have shown that neither ankle blood pressure nor calf muscle blood flow is improved by walking exercise that results in symptomatic relief. The improve ments achieved are probably due to more efficient oxygen extraction from the limited blood supply. Aspirin should probably be given to all patients with vascular disease as a recent meta analysis has demonstrated its efficacy in reducing vascular mortality, myocardial infarction and non-fatal stroke. Case 2 Mr P. C. is a 63-year-old insurance broker. He attended with a 3-week history of pain in the calf of his left leg on walking 1 mile. For recreation he was a member of a walking club and did a lot of walking over long distances at the weekends. His symptoms had seriously impaired this activity. When he initially experienced the symptom he thought it was a cramp in the muscle of his calf. In his past medical history he suffered from hypertension for which he was on chlorhalidone 50 mg daily. He had been a smoker of 20 cigarettes a day until 8 years previously, when he stopped smoking. On examination, he was a thin, fit man, who looked his stated age. His pulse was 66 per min and regular, and his blood pressure was 170/100. On examination his legs were of normal colour with no pallor on elevation or rubor when dependent. His legs looked healthy and well perfused. The temperature was normal, and equal bilaterally. Examination of his abdomen revealed no abnormalities. In particular there was no evidence of abdominal aortic aneurysm. His femoral pulses were normal and equal bilaterally, and there were no bruits audible in the abdomen or in the groin. Both popliteal pulses were palpable and there was no evidence of popliteal aneurysm. Auscultation over the medial thigh in the region of the left superficial femoral artery revealed a soft bruit. Examination of the pedal pulses revealed palpable dorsalis pedis pulses and absent posterior tibial pulses bilaterally. 3 collateral circulation, a number of studies have shown that neither ankle blood pressure nor calf muscle blood flow is improved by walking exercise that results in symptomatic relief. The improve ments achieved are probably due to more efficient oxygen extraction from the limited blood supply. Aspirin should probably be given to all patients with vascular disease as a recent meta analysis has demonstrated its efficacy in reducing vascular mortality, myocardial infarction and non-fatal stroke. Case 2 Mr P. C. is a 63-year-old insurance broker. He attended with a 3-week history of pain in the calf of his left leg on walking 1 mile. For recreation he was a member of a walking club and did a lot of walking over long distances at the weekends. His symptoms had seriously impaired this activity. When he initially experienced the symptom he thought it was a cramp in the muscle of his calf. In his past medical history he suffered from hypertension for which he was on chlorhalidone 50 mg daily. He had been a smoker of 20 cigarettes a day until 8 years previously, when he stopped smoking. On examination, he was a thin, fit man, who looked his stated age. His pulse was 66 per min and regular, and his blood pressure was 170/100. On examination his legs were of normal colour with no pallor on elevation or rubor when dependent. His legs looked healthy and well perfused. The temperature was normal, and equal bilaterally. Examination of his abdomen revealed no abnormalities. In particular there was no evidence of abdominal aortic aneurysm. His femoral pulses were normal and equal bilaterally, and there were no bruits audible in the abdomen or in the groin. Both popliteal pulses were palpable and there was no evidence of popliteal aneurysm. Auscultation over the medial thigh in the region of the left superficial femoral artery revealed a soft bruit. Examination of the pedal pulses revealed palpable dorsalis pedis pulses and absent posterior tibial pulses bilaterally. 4 Comment This history and presentation is typical of mild claudication in a chronic smoker. The clinical and anatomical diagnosis is readily made by history and physical examination. Thus left superficial femoral stenosis is the clinical diagnosis. Routine tests included full blood count, blood glucose, urinalysis, chest X-ray and cardio graph, which showed no abnormality. Segmental Doppier pressu res were carried out and showed the ankle systolic pressure index on both sides to be greater than 1.0. However, the Doppler pressure on the left hand side was 125 compared with 135 on the other side. The segmental Doppler pressures were repeated following exercise, after which the ankle systolic pressure on the left side fell to 0.66, while on the right side it remained greater than 1.0 as before. This finding supported the diagnosis of superficial femoral arterial stenosis, and aortography was carried out. Transfemoral aortography showed a normal aorta and normal iliac arterial system bilaterally. The arterial tree below the inguinal ligament was normal on both sides, apart from a 6 cm long stenosis in the left superficial femoral artery, extending distally to Hunter's canal. This lesion appeared to be one which would be amenable to percutaneous transluminal balloon angioplasty. This was carried out by insertion of a cannula in the left superficial femoral artery and the passage of a balloon dilatation catheter over a guide wire through the superficial femoral arterial stenosis. This resulted in recanalization of the superficial femoral artery. The day following this procedure, the patient again had segmental Doppler pressures measured. These were normal and equal on both sides. The patient was discharged on aspirin 300 mg daily and returned 2 weeks later for further exercise studies. On exercise on this occasion the systolic pressure did not fall on the left side and remained greater than 1.0. Discussion This patient had a relatively benign form of claudication. However it interfered with his hobby of hill walking. Although the diagnosis was clinically suspected by virtue of the history and bruit over the adductor canal, resting segmental pressures were normal. Only 5 after exercise did the pressure fall, thus clinching the diagnosis. This stenosis was suitable for angioplasty although its length is at the upper limit of suitability. Treatment was offered because of the low risk of angioplasty and the probability of restoring the patient's ability to participate in long distance walking. Case 3 Mr J. K. was a 63-year-old farmer. He presented with intermittent claudication in his right calf which had become progressively worse over the previous 6 months. He could now walk no more than 50 yards. He experienced no pain at rest, although he had on occasion experienced a sensation of 'numbness' and 'coldness' in his toes, and occasionally pain in bed at night. He had smoked 40 cigarettes a day since the age of 14. His doctor saw him 6 weeks prior to referral and had prescribed oxypentifylline 200 mg tid. The patient reported no benefit from this. On examination Mr J. K. was a thin, unhealthy looking man, whose facial appearance would suggest that he was in his seven ties. His pulse was regular in volume and rhythm (80 per min) and his blood pressure was 140/90. Examination of his respiratory system showed features con sistent with chronic obstructive airways disease. There was no evidence of an abdominal aortic aneurysm. He had normal femoral pulses bilaterally with absent popliteal and pedal pulses in both lower limbs. He had no evidence of popliteal artery aneurysm and had a bruit which was maximal just below his femoral pulse on the right side. He had no ulcération in his feet or other features of critical ischaemia and had no evidence of neuropathy. Routine testing revealed a haemoglobin of 16.4 g%, normal chest X-ray, blood glucose and urinalysis and there was electrocar diographs evidence of an old subendocardial infarcì. Comment This gentleman presents with rapidly progressive intermittent claudication with one or two minor episodes of rest pain. On
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