Page 142 - Libro 2

122 PART 3 — PERIPHERAL ARTERIAL TABLE 8-1
Variations in Leg Pain
Condition
Intermittent claudication Spinal stenosis
Location
Buttock, thigh, hip, calf As previous
Associated with Exercise?
Always
Yes, but also with standing
Variable
Variable, not always produced
Relieved by?
Stopping
Sitting; flexing and moving spine Varies; aspirin or
anti-inflammatories Varies; aspirin or
anti-inflammatories
Herniated disc Radiates down leg Osteoarthritis Hips, knees, ankles
to the site and severity of the disease. The amount of activity that produces the symptoms can remain fairly reproducible for long periods unless there is accelerated progression of the PAOD. The site of the symptoms indicate the site(s) of the disease because they occur distal to the disease process, so claudi- cation limited to the calf is associated with superfi- cial femoral/popliteal or tibial artery disease, thigh symptoms with iliofemoral artery disease, and but- tock claudication with either ipsilateral iliofemoral (if unilateral) or aortoiliac disease when bilateral.
It is important to distinguish between the causes of leg discomfort resulting from activity, especially for the mechanism(s) that result in the loss of postac- tivity symptoms.1 Cessation of symptoms with quiet standing corresponds to true ischemic intermittent claudication, whereas correction requiring sitting and/or spinal flexure is more associated with spinal stenosis (Table 8-1). Claudication distances will decrease and symptom recovery time will increase as PAOD progresses, sometimes being accompanied by the signs of thickening of toenails and loss of toe hair. At the most severe levels of PAOD, the skin may be- come discolored and scaly and forefoot pain may be constant with claudication distance less than 50 ft. At these severe levels, raising the leg a foot or so above heart level will usually cause blanching of the skin on the foot, but which becomes red with dependency— elevation pallor/dependent rubor. Blueness of the toes, perhaps unilateral, can be the first indication of aneurysmal disease. This happens with embolization of aneurysm contents into distal segments of the limb and can progress to gangrene. The most common site for a peripheral aneurysm is at popliteal level, although these are associated more with sudden oc- clusion rather than with embolization.
PAOD in the upper extremity is encountered in 􏰀5% of all cases.2 Typically, it is restricted to numb- ness, aching or tiredness associated with position- al extrinsic compression in the shoulder girdle, or to cold-related vasospasm. Approximately 95% of all extrinsic compression-related symptoms have
neurovascular origins, with only 3% to 4% from ve- nous compression and arterial in only 1% to 2%.3 This spectrum of symptoms are grouped as thoracic outlet syndrome (TOS).
Cold sensitivity is an intense episodic vasospasm related to cold exposure or to emotional stress.4 It is generally referred to as Raynaud’s phenomenon. It comprises both Raynaud’s disease (also known as primary Raynaud’s phenomenon) and Raynaud’s syn- drome (or secondary Raynaud’s). The cause of primary Raynaud’s is idiopathic. Secondary Raynaud’s is asso- ciated with an underlying process such as scleroderma or trauma. The primary condition is usually bilateral, involving most of the digits (although the thumbs may be spared), whereas secondary causes may be unilat- eral, perhaps even affecting a single digit.
The various types of nonimaging tests that are com- monly used to detect the presence of PAOD include systolic pressure determinations, Doppler waveforms, plethysmography, and photoplethysmography. These tests help determine overall limb perfusion and, thus, serve as an indicator of the functional status of a limb. However, they are less dependable when PAOD occurs at multiple levels because moderate-to-severe disease proximally can reduce flow energy distally, masking the presence of distal PAOD. This chapter will describe these indirect testing modalities, applications for such testing, and diagnostic criteria.
EXAMINATION PREPARATION
Although there are various types of indirect vascular tests, all have similar preparations that are needed prior to the start of testing. Proper patient preparation and positioning are required for adequate results.
PATIENT PREPARATION
The study starts with confirming the identity of the patient and verifying that the study ordered is ap- propriate to the patient’s signs and/or symptoms.