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With Free Saver Delivery. Facebook Twitter Pinterest Share. Description Also available on eBook. Click here to purchase from Kobo. About the Author Dr. Edward B. Diethrich, an internationally renowned cardiovascular surgeon who has practiced for more than 40 years, is regarded as one of the world's pioneers in heart disease diagnosis and innovative cardiovascular and endovascular treatments. Diethrich is the Medical Director and Chief of Cardiovascular Surgery at the Arizona Heart Hospital, where he performs state-of-the-art endovascular procedures using the latest devices, many of which he helped design and test in clinical trials.

Polydorou performed the first successful treatment of a renal artery aneurysm RAA in October Free Returns We hope you are delighted with everything you buy from us. However, if you are not, we will refund or replace your order up to 30 days after purchase. The symptoms in patients with arterial failure in the limbs caused by chronic arterial disease can be stratified according to the classification of Leriche-Fontaine Table 1. This classification, which groups patients who have progressive arterial failure into 4 stages, has prognostic value and is very useful for treatment indication..

Stage I is characterized by the absence of symptoms. It includes patients with arterial disease but no clinical repercussions. This should not be associated with a benign course of the disease. It is obvious that patients who have an extensive occlusive arterial lesion in the legs, who have a sedentary lifestyle or who are incapacitated due to osteoarticular, or neurologic disease will not present symptoms of arterial failure.

In these situations, the patients may present with critical ischemia straight from an asymptomatic stage..

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Stage II is characterized by the presence of intermittent claudication. This stage is itself divided into groups. Stage IIa includes patients with non-invalidating claudication or at long distances. Stage IIb refers to patients with short claudications or claudications that impede activities of daily living..

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The intermittent claudication that is typical in patients with PAD is defined as the appearance of pain in muscle masses caused by walking and which ceases immediately after stopping exercise. It is important to note that the pain always presents in the same muscle groups and after covering a similar distance, provided the same slope and speed are maintained.. A great number of patients report pain in the legs associated with walking, but not with the presence of arterial disease.

Many of them have muscle, osteoarticular, or neurologic diseases, and these may occasionally coexist with obstructive arterial disease. In these cases it is very important to establish a correct differential diagnosis, which initially will be clinical and later will be confirmed with non-invasive studies.


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The clinical presentation in these patients usually concerns joint pain related with exercise, but also during passive movement of the limb. When the symptoms concern muscle pains, the pains do not usually present systematically at the same place, and are often not localized to muscle groups involved in walking glutei, quadriceps, and calf muscles. The walking distance with these non-vascular claudications varies considerably, even over the day.

However, the pain does not cease simply by stopping walking, but rather the patient has to sit down, lie down, or adopt a special posture, with the symptoms usually disappearing after a much longer period of rest than required with vascular claudication.. The muscle group affected during gait is useful for determining the site of the occlusive lesion. Although most patients report calf muscle claudication, the presence of claudication in the buttocks or thighs may indicate the presence of disease in the iliac region.

Claudication due to femoropopliteal disease is typically located in the calf muscles, and infrapopliteal occlusions may only manifest themselves as claudication in the sole of the foot Table Stage III constitutes a more advanced phase of ischemia and is characterized by the presence of symptoms at rest.

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The predominant symptom is usually pain, although the patient often reports paresthesia and hypoesthesia, usually at the front of the foot and the toes. Paresthesia at rest may be indistinguishable from that due to diabetic neuropathy, although in the latter the paresthesia is usually bilateral, symmetrical, and with a "sock distribution. This is the cause of the appearance of distal edema in the limb due to the continued dangling. In stage III the patient usually has a cold limb with a variable degree of paleness.

Some patients with more intense ischemia, however, have erythrosis of the dangling foot due to extreme cutaneous vasodilatation, which is called the "lobster foot. Stage IV is characterized by the presence of trophic lesions. It is due to the critical reduction of distal perfusion pressure, insufficient to maintain tissue trophism.

These lesions are situated in the more distal areas of the limb, usually the toes, although on occasions they may present in the malleolus or the heel. They are usually very painful, except in diabetic patients with associated neuropathy, and are very susceptible to infection.. The basic examination of the arterial system is based on the evaluation of the presence of pulses, which in the lower limbs will include the search in the femoral, popliteal, pedal, and posterior tibial arteries.

In the event of aortoiliac occlusive disease a reduction in all the pulses in the limb or their complete absence will be evident. In the case of femoropopliteal disease, the femoral pulse will be present, but it will be absent in the popliteal and distal arteries. Auscultation of the abdomen will enable identification of the presence of murmurs, which are indicative of disease in the aorta or the iliac arteries. Auscultation of the inguinal region may reveal the presence of lesions in the external iliac or femoral bifurcation vessels. It is also important to check the temperature, color, and trophism of the foot.

Patients with claudication do not usually show a reduction in temperature or capillary filling. The reduction in temperature, however, and paleness, with or without cyanosis or dangling erythrosis, are common in patients with critical ischemia. Finally, clinical examination of the upper limbs should not be forgotten as well as cervical auscultation due to the great prevalence of carotid lesions or supra-aortic trunk lesions, which in most cases are subclinical..

After the initial clinical and physical examination, patients with suspected occlusive arterial disease should be studied in a non-invasive vascular examination laboratory. This evaluation enables the degree of functional involvement to be quantified and the occlusive lesions to be localized. The basic study consists of recording the segmental pressures of the limb upper thigh, lower thigh, calf, and ankle by means of Doppler ultrasound to detect flow in the malleolar arteries anterior tibial, posterior tibial, and fibula.

Comparison between the systolic pressure obtained in the brachial artery and that obtained in the different segments of the leg permits the site of the lesion to be determined and provides information about the intensity of the hemodynamic involvement.. Recording the pulse wave volumes along the limb by plethysmography is particularly useful in patients in whom arterial calcification prevents a reliable recording of systolic pressures. Transmetatarsal or digital recording provides important information about the state of the vascularization in this zone, which is difficult to obtain with other techniques Figure Figure 1.

Study of segmental pressures and wave volume according to the affected sector. A: normal study: pulse wave volumes PWV with dicrotic wave.


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C: femoropopliteal occlusion: normal PWV and indices in proximal thigh. D: intense calcification: the vessels do not collapse despite the very high sleeve pressures falsely high ankle-arm index. Very pathologic PWV, transmetatarsal planes.. Finally, recording the velocimetric wave obtained by Doppler can also provide very useful information by means of evaluating the changes in the different components of the arterial velocimetric wave Figure Figure 2.

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Doppler velocimetric wave. A: normal study. Prominent systolic wave with dicrotism in the descending wave. B: mildly pathologic study. Absence or reduction of the dicrotism in the descending wave. C: very pathologic study. Flattening of the systolic wave.. Some patients may have symptoms of typical claudication at mid-long distance, but with a study and ABI within normal ranges. In these cases it is convenient to carry out a claudicometry, which consists of the measurement of the ABI after walking on a treadmill.

A normal physiological response consists of a rise in the pressure at the ankle in response to exercise. When an occlusive lesion is present that is not important at rest, this can be shown up by a reduction in the ABI with exercise. This method enables the symptoms of the patients to be reproduced objectively and the claudication distance quantified. In the case of claudication of non-vascular origin, the ABI will not fall and the studies to be undertaken can then be adequately oriented..

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Imaging techniques are indicated if surgical or endovascular repair is contemplated after identification of a susceptible lesion. The clinical situation short or progressive claudication, pain at rest, or trophic lesions is the main factor to be evaluated regarding the indication for surgery. Angiography remains the reference study, but it involves certain risks, such as intense reactions to iodized contrast material, the possibility of worsening renal function, and other local complications, like dissection, atheroemboly, or problems related with the access site hemorrhage, pseudoaneurysm, or arteriovenous fistula..

Echo-Doppler is a less costly and safer technique. In expert hands, it can reliably show the main anatomic characteristics in order to undertake revascularization. Its main limitations concern the fact that it is excessively dependent on the operator, that it has a poor reliability in the evaluation of the infrapopliteal vessels and the time required to carry out a complete examination..

Both multislice computerized angiotomography and magnetic resonance angiography are being increasingly used for the diagnosis and surgical planning. Magnetic resonance angiography enables 3-dimensional images to be obtained safely of the whole abdomen, the pelvis, and the lower limbs at 1 single study.