Evaluation of Leg Pain

2015 ◽  
Author(s):  
Martyn Knowles
Keyword(s):  
Lower Extremity ◽  
Ankle Brachial Index ◽  
Limb Ischemia ◽  
Arterial Disease ◽  
Cardiac Risk ◽  
Multiple Organ ◽  
Leg Pain ◽  
Acute Limb Ischemia ◽  
Organ Systems ◽  
Peripheral Arterial

Few patient complaints offer such a large range of acuity and differential diagnoses as the complaint of leg pain. This is in part due to the multiple organ systems at play, including cardiac, pulmonary, musculoskeletal, neurologic, vascular, and dermatologic. The surgeon is frequently presented with the challenge of identifying and managing these complaints in a variety of settings. Management involves a spectrum from conservative care to surgical intervention where appropriate. The wide array of symptoms, signs, and often contradictory test results can be confusing and frustrating to patients and physicians alike, leading to delays and errors in diagnosis and ineffective management. This review offers a sequential and ordered approach to the evaluation of leg pain. Tables highlight atherosclerotic risk factors, vascular causes of lower extremity pain, the classification of acute limb ischemia, the ankle-brachial index and corresponding peripheral arterial disease, and the revised cardiac risk score for preoperative risk. Figures show bilateral lower extremity ischemia, chronic ischemic changes to the foot, classic dry gangrene, wet gangrene, acute limb ischemia, Charcot foot, segmental waveform and pulse volume recording analysis of the bilateral lower extremities, and angiographic evaluation of patients with aortoiliac and tibial disease. This review contains 10 figures, 5 tables, and 55 references.

scholarly journals Physiology in Medicine: Peripheral arterial disease

2013 ◽  
Vol 115 (9) ◽  
pp. 1219-1226 ◽  
Author(s):  
Matthew D. Muller ◽  
Amy B. Reed ◽  
Urs A. Leuenberger ◽  
Lawrence I. Sinoway
Keyword(s):  
Peripheral Arterial Disease ◽  
Physical Inactivity ◽  
Treatment Options ◽  
Arterial Disease ◽  
Multiple Organ ◽  
Leg Pain ◽  
Organ Systems ◽  
All Cause Mortality ◽  
Peripheral Arterial ◽  
Medicine Review

Peripheral arterial disease (PAD) is an atherosclerotic condition that can provoke symptoms of leg pain (“intermittent claudication”) during exercise. Because PAD is often observed with comorbid conditions such hypertension, dyslipidemia, diabetes, cigarette smoking, and/or physical inactivity, the pathophysiology of PAD is certainly complex and involves multiple organ systems. Patients with PAD are at high risk for myocardial infarction, stroke, and all-cause mortality. For this reason, a better physiological understanding of the pathogenesis and treatment options for PAD patients is necessary and forms the basis of this Physiology in Medicine review.

Abstract P250: Incidence of Hospitalized Peripheral Arterial Disease and Critical Limb Ischemia: The Atherosclerosis Risk in Communities (ARIC) Study

Circulation ◽  
2012 ◽  
Vol 125 (suppl_10) ◽  
Author(s):  
Corey A Kalbaugh ◽  
Anna Kucharska-Newton ◽  
Laura Loehr ◽  
Elizabeth Selvin ◽  
Aaron R Folsom ◽  
...  
Keyword(s):  
Risk Factors ◽  
African Americans ◽  
Peripheral Arterial Disease ◽  
Lower Extremity ◽  
Limb Ischemia ◽  
Arterial Disease ◽  
Atherosclerosis Risk In Communities ◽  
Atherosclerosis Risk ◽  
Baseline Characteristics ◽  
Peripheral Arterial

Introduction: Lower extremity peripheral arterial disease (PAD) affects between 12% and 20% of Americans over the age of 65. PAD compromises quality of life, contributes a high burden of disability and its related health care costs exceed $4 billion/year, yet this preventable CVD outcome remains understudied. Aims: Assess the incidence of hospitalized PAD, and of the most severe form of PAD, critical limb ischemia (CLI), in middle-aged men and women, and evaluate their risk factors in a bi-ethnic, population-based cohort. We hypothesized that incidence of hospitalized PAD and CLI are higher in African Americans, and that modifiable atherosclerosis risk factors in middle age predict these sequelae of PAD. Methods: We analyzed data from 13,865 participants from the Atherosclerosis Risk in Communities Study aged 45–64 without PAD at baseline (1987–89). Incident PAD and CLI events were identified using ICD-9 codes from active surveillance of all hospitalizations among cohort participants from 1987 through 2008. All estimates are incidence rates per 10,000 person-years; nominal statistical significance was achieved for all baseline characteristic comparisons reported. Results: There were 707 incident hospitalized PAD during a median of 18 years of follow-up (249,570 person-years). The overall age-adjusted incidence of PAD and limb-threatening CLI were 26.0 and 9.6 per 10,000 person-years, respectively. Incidence of hospitalized PAD was higher in African Americans than whites (34.7 vs. 23.2) and in men compared to women (32.4 vs. 26.7). Baseline characteristics associated with age-adjusted incident PAD (per 10,000 person-years) compared to their referent groups were diabetes (91.2 vs. 19.0), history of smoking (33.6 vs. 16.2), hypertension (42.6 vs. 18.6), coronary heart disease (81.4 vs. 24.1), and obesity (41.5 vs. 20.2). Incidence of CLI also was higher among African Americans (21.0 vs. 5.9) and in men (10.5 vs. 8.9 per 10,000 person-years). Baseline characteristics associated with incident CLI were similar to those for PAD. Conclusions: The absolute risk of hospitalized lower extremity PAD in this community-based cohort is of a magnitude similar to that of heart failure and of stroke. As modifiable factors are strongly predictive of the long-term risk of hospitalized PAD and CLI, particularly among African Americans, our results highlight the need for effective risk factor prevention and control.

Impact of Kidney Disease on Peripheral Arterial Interventions: A Systematic Review and Meta-Analysis

2020 ◽  
Vol 51 (7) ◽  
pp. 527-533
Author(s):  
Mahesh Anantha-Narayanan ◽  
Azfar Bilal Sheikh ◽  
Sameer Nagpal ◽  
Kim G. Smolderen ◽  
Jeffrey Turner ◽  
...  
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Meta Analysis ◽  
Limb Ischemia ◽  
Arterial Disease ◽  
Major Amputation ◽  
Early Mortality ◽  
Comorbid Condition ◽  
Increased Risk ◽  
Peripheral Arterial

Background: There are limited data on outcomes of patients undergoing peripheral arterial disease (PAD) interventions who have comorbid CKD/ESRD versus those who do not have such comorbid condition. We performed a systematic review and meta-analysis to analyze outcomes in this patient population. Methods: Five databases were searched for studies comparing outcomes of lower extremity PAD interventions for claudication and critical limb ischemia (CLI) in patients with CKD/ESRD versus non-CKD/non-ESRD from January 2000 to June 2019. Results: Our study included 16 observational studies with 44,138 patients. Mean follow-up was 48.9 ± 27.4 months. Major amputation was higher with CKD/ESRD compared with non-CKD/non-ESRD (odds ratio [OR 1.97] [95% confidence interval [CI] 1.39–2.80], p = 0.001). Higher major amputations with CKD/ESRD versus non-CKD/non-ESRD were only observed when indication for procedure was CLI (OR 2.27 [95% CI 1.53–3.36], p < 0.0001) but were similar for claudication (OR 1.15 [95% CI 0.53–2.49], p = 0.72). The risk of early mortality was high with CKD/ESRD patients undergoing PAD interventions compared with non-CKD/non-ESRD (OR 2.55 [95% CI 1.65–3.96], p < 0.0001), which when stratified based on indication, remained higher with CLI (OR 3.14 [95% CI 1.80–5.48], p < 0.0001) but was similar with claudication (OR 1.83 [95% CI 0.90–3.72], p = 0.1). Funnel plot of included studies showed moderate bias. Conclusions: Patients undergoing lower extremity PAD interventions for CLI who also have comorbid CKD/ESRD have an increased risk of experiencing major amputations and early mortality. Randomized trials to understand outcomes of PAD interventions in this at-risk population are essential.

scholarly journals Evaluation of Patients with Lower Extremity Peripheral Artery Disease by Walking Tests: A Pilot Study

2017 ◽  
Vol 9 (4) ◽  
pp. 467-473 ◽  
Author(s):  
Andra CIOCAN ◽  
Răzvan A. CIOCAN ◽  
Claudia D. GHERMAN ◽  
Sorana D. BOLBOACĂ
Keyword(s):  
Lower Extremity ◽  
Arterial Disease ◽  
Leg Pain ◽  
Walking Ability ◽  
Treadmill Test ◽  
Walking Test ◽  
Randomized Design ◽  
Walking Tests ◽  
Peripheral Arterial ◽  
Surgery Department

Peripheral arterial disease (PAD) directly affects the quality of life, patients experimenting limited walking ability and disability. The purpose of the current study was to investigate the walking and climbing patterns of patients with lower extremity PAD in relation with several risk factors, applied on Romanian population. A cohort non-randomized design was conducted and all eligible subjects who self-referred for medical care since March 2016 until February 2017 at the Second Surgery Department, County Clinical Emergency Hospital of Cluj-Napoca were included. The eligible patients were older than 18 years, with leg pain and Rutherford grade from I to IV. The following tests were applied to each subject included in the study to investigate the capacity to walk as far as possible in six minute (6 minute walking test), the capacity to climb stairs (climbing stairs test) and the capacity to walk on a treadmill (treadmill test) until the pain occurred. Twenty-four patients with mean age of 65.08±8.53 years were investigated. Almost 81% of patients were with chronic pain, 46% were overweight, and 79% were smokers. The results on applied walking tests were as follows: 279.17±70.58 meters to 6-minutes walking test, 77.50±21.80 stairs and 182.50±73.34 meters on treadmill test. The results of the walking tests significantly correlate with each other (ρ>0.93, p<0.0001), and all applied tests significantly correlate with toe gangrene (ρ>|0.52|, p<0.01) and toe disarticulation (ρ>0.62, p<0.002). It can be concluded that any of the applied walking test proved reliable instrument, able to identify the patients with most severe PAD.

Endovascular Procedures For Lower Extremity Vascular Disease: Basics of Endovascular Intervention

2018 ◽  
Author(s):  
Lalithapriya Jayakumar ◽  
Mark Davies
Keyword(s):  
Lower Extremity ◽  
Vascular Disease ◽  
Endovascular Procedures ◽  
Vascular Diseases ◽  
Limb Ischemia ◽  
Arterial Disease ◽  
Surgical Approaches ◽  
Acute Ischemia ◽  
Acute Limb Ischemia ◽  
Access Complications

The application of endovascular procedures to lower-extremity vascular disease is well established for many common vascular diseases and has often supplanted conventional open surgical approaches. Endovascular therapy for arterial disease in the lower extremity encompasses treatment of acute ischemia, chronic ischemia, and aneurysmal disease. The fundamental skill set and techniques employed are common to all these processes. This chapter details these techniques and therapies. Key words: access closure, access complications, acute limb ischemia, chronic limb ischemia, intravascular ultrasonography, lower-extremity angiogram, transcollateral access, transpopliteal access

Endovascular Procedures For Lower Extremity Vascular Disease: Basics of Endovascular Intervention

2018 ◽  
Author(s):  
Lalithapriya Jayakumar ◽  
Mark Davies
Keyword(s):  
Lower Extremity ◽  
Vascular Disease ◽  
Endovascular Procedures ◽  
Vascular Diseases ◽  
Limb Ischemia ◽  
Arterial Disease ◽  
Surgical Approaches ◽  
Acute Ischemia ◽  
Acute Limb Ischemia ◽  
Access Complications

The application of endovascular procedures to lower-extremity vascular disease is well established for many common vascular diseases and has often supplanted conventional open surgical approaches. Endovascular therapy for arterial disease in the lower extremity encompasses treatment of acute ischemia, chronic ischemia, and aneurysmal disease. The fundamental skill set and techniques employed are common to all these processes. This chapter details these techniques and therapies. Key words: access closure, access complications, acute limb ischemia, chronic limb ischemia, intravascular ultrasonography, lower-extremity angiogram, transcollateral access, transpopliteal access

The Correlation between Symptoms and Non-Invasive Test Results in Patients Referred for Peripheral Arterial Disease Testing

1996 ◽  
Vol 1 (1) ◽  
pp. 65-71 ◽  
Author(s):  
Michael H Criqui ◽  
Julie O Denenberg ◽  
Cameron E Bird ◽  
Arnost Fronek ◽  
Melville R Klauber ◽  
...  
Keyword(s):  
Peripheral Arterial Disease ◽  
Residual Disease ◽  
Ankle Brachial Index ◽  
Arterial Disease ◽  
Leg Pain ◽  
Non Invasive ◽  
Invasive Test ◽  
Peripheral Arterial ◽  
Pain At Rest ◽  
Specific Symptoms

The WHO/Rose questionnaire has served as the epidemiologic and clinical standard in the assessment of leg pain in patients with peripheral arterial disease (PAD) for over three decades. However, the structure of this questionnaire does not allow assessment of leg-specific (i.e. right versus left) symptoms. We studied 508 patients aged 39–95 years (mean 68 years), initially referred for PAD non-invasive testing. A revised questionnaire, the San Diego Claudication Questionnaire, was administered which allowed determination of leg-specific symptoms and evaluated thigh and buttock as well as calf pain. Leg-specific symptoms were categorized into no pain, pain at rest, non-calf claudication, non-Rose calf claudication, and Rose claudication. At the same visit, the ankle brachial index, the toe brachial index, and peak posterior tibial flow velocity were measured by Doppler ultrasound and five categories of non-invasive results by type and severity of PAD were defined. Legs with previous intervention (Rx), surgery or angioplasty, were evaluated separately. Claudication was reported in 42% of no Rx legs and 50% of Rx legs; 40% of claudication was atypical (not Rose); 64% of no Rx and 81% of Rx legs had PAD by non-invasive testing, and 27% of affected legs had severe PAD. The correlation between the severity of symptoms and the severity of ipsilateral PAD in no Rx legs was r=−0.40, p< 0.001. In Rx legs, this correlation was somewhat less ( r=0.27, p< 0.001) due to more symptomatology at lesser degrees of PAD, suggesting reporting bias and/or more residual disease than evident from non-invasive testing. To our knowledge, these results provide the first comparison between a standardized assessment of leg pain and the severity of ipsilateral PAD by non-invasive testing.

Claudication as an ‘Orphan Disease’: Rationale and Goals of Drug Therapy for Peripheral Arterial Disease

1996 ◽  
Vol 1 (1) ◽  
pp. 37-42 ◽  
Author(s):  
Alan T Hirsch
Keyword(s):  
Peripheral Arterial Disease ◽  
Disease Progression ◽  
Critical Role ◽  
Ankle Brachial Index ◽  
Arterial Occlusion ◽  
Limb Ischemia ◽  
Arterial Disease ◽  
Current Data ◽  
History Of ◽  
Peripheral Arterial

Patients with peripheral arterial disease are often perceived to suffer from a disorder whose pathogenesis and symptoms are not amenable to drug therapies. This clinical misperception remains prevalent despite an abundance of data suggesting that diverse pharmacotherapies may modulate the natural history of this disease. Patients with chronic limb arterial occlusive disease suffer from a disease that is characterized by: (1) a prolonged asymptomatic state that can be identified by simple physical examination and confirmed by measurement of the ankle brachial index; (2) a multi-year period of symptomatic claudication; and (3) a variable rate of progression to critical limb ischemia or acute arterial occlusion. This stage-dependent disease progression is mediated via the dynamic, but as yet incompletely understood, interaction of factors that elicit endothelial dysfunction, atherogenesis, and thrombosis. Current data suggest that each of these contributory disease processes can be modulated by extant pharmacotherapies. Additionally, many novel pharmacotherapeutic agents that are currently under investigation may further improve the ability of clinicians to modulate these fundamental biologic processes. Pharmacologic therapies should be targeted to decrease the rate of limb arterial disease progression, to improve limiting symptoms, and to prolong life. Symptoms of claudication can be objectively assessed via both exercise testing and disease-specific questionnaires. The presence of lower extremity atherosclerotic disease is predictive of the presence of coronary heart disease and a foreshortened five-year survival. Current data suggest that clinical investigations should be able to effectively stratify this relative risk via use of both clinical variables (e.g., age, diabetes mellitus, tobacco use, etc.) or by measurement of the ankle brachial index (ABI). The role of the physician is to decrease suffering and to prolong life. Judicious administration of medical therapies can play a critical role in helping the vascular practitioner accomplish these goals.

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