Peripheral Arterial Disease (Lower Limb Ischemia)

Clinical features

Intermittent claudication, pain relieved on hanging the leg from bed, coldness, numbness, paraesthesia, impotence signs, sensation, color changes, ulceration, gangrene, low temperature, absent no arterial pulsation distal to obstruction.

Investigations

CBC, ESR, RBS, lipid profile, ECG, ECHO, Doppler Ultrasound, CT angiography and MRA

Diagnosis

The ratio of systolic blood pressure detected by doppler examination at the ankle compared with the brachial artery (referred) to as the ankle - brachial index (ABI) is reduced to below 0.9 (normal ratio is 0.9-1.2).

• Diagnose PAD with ABI if patient has one or more of the following: Exertional leg symptoms, nonhealing wounds, age > 65, age > 50 with history of diabetes or smoking.
• Measure ABI in both legs to establish a baseline and confirm diagnosis. If ABI not reliable because of noncompressible vessels, use toe brachial index.
• Use leg segmental pressures to anatomically localize PAD

Management: General measures

Tell the patient, walking is not harmful, stop smoking, do regular exercise ( Burger exercise , repeated 2 min elevation and dependency of limb ) , reduces weight , take care of feet , and sleep in burger position ( elevation of head end of the patient ).

Pharmacological treatment: CMDT

• Tab - Aspirin (Ascard) 81mg 1 tab PO X OD
• Tab- Rosuvastatin (Crescor) 10-20 mg 1 tab PO x OD at night
• Tab Cilostazole (Pletaal / Lostaz) 100mg 1 tab PO x BD
• Supportive care for other complaints
• Tab- Naproxen (synflex) 500mg 1tab PO x BD ' OR '
• Tab Paracetamol + orphenadrine (Nuberol forte) 1 tab PO x TDS
• Inj- Ranitidine (zantac) 50 mg IV x BD
• Treat co - morbidities like hypertension and diabetes etc.
• If no improvement after 6months then stenting, angioplasty and endartrectomy should be performed.
• In case of burger disease sympathectomy and prostaglandin infusion may be helpful, otherwise amputation is the last resort.