Interactive Case Presentation Happy Foot

Philippine Heart Association

Interactive Case Presentation

“ Happy Foot ”

Ruby Rose S. Cacatian, MD

St. Luke’s Medical Center

General Data

81 y/o, female

married, Chinese

from Quezon City

Chief Complaint:

non-healing wound, L

History of Present Illness

11 months

• Pain on the leg pain L>R upon walking <200 m• L leg pain radiates to to the 5th digit L foot

• (-) skin changes or visible lesions• (-) trauma

• advised an arterial duplex scan of lower extremeties showed occluded LE arteries

• Persistent leg pain

• consult with Rheumatologist: Arthritis • given steroid injection plantar aspect of L lateral

foot• open wound post injection site

• persistent non-healing wound, lateral aspect of the 5th digit, L foot

• leg pain at rest relieved by dangling LE

• difficulty walking

• underwent debridement of the wound in local hospital

• no improvement in the wound, no relief of leg pain

• advised amputation

2 months PTA

1 month PTA

• Deterioration of the non-healing

wound and development of

gangrene involving the 5th digit, L foot

• intolerable leg pain worst at night

Referred to vascular service

Few days

Review of Systems

• General: (-) fever (+) weight loss

• Integumentary: no rashes (-) bleeding tendencies

• HEENT: (-)headache (-) dizziness (-) eye pain (-) blurring

of vision

• Cardiovascular: (-) exertional dyspnea, (-) easy

fatigability, (-) chest pain, (-) palpitations, (-) syncope

• Pulmonary: (-) pleurisy

• Gastrointestinal: (+) loss of appetite (-) nausea/vomiting

(-) change in bowel habits (-) abdominal discomfort

• Genitourinary: (-) dysuria (-) hematuria

• Neurologic: (-) dizziness (-) loss of consciousness (-)

paralysis

Past Medical History

• Diabetic x 30 years

– Sitagliptin/Metformin 50/500 BID

– Glimepiride 2mg/tab OD

• Hypertensive x 30 years

– Telmisartan 40 mg tablet OD

– Diltiazem 60 mg tablet OD

Past Medical History

• Dyslipidemic on Atorvastatin 20 mg tablet ½ OD

• Other meds:

– Cilostazol 100 mg/tab OD

– Clopidogrel 75 mg/tab OD

– Beraprost 20ug/tab TID

• (+) Colon CA-20 years ago S/P Colon Resection

• (+) PTB – treated 2007

Personal and Social History:

• non-smoker

• non-alcoholic beverage drinker

Physical Examination

General Survey: Conscious, coherent, wheel-chair borne

BP= 160/90 R arm, 150/90 L arm,

130/70 R leg, L leg BP cannot be appreciated

HR=60 bpm,reg RR=20, Temp=36.6 ⁰C,

Weight=41.3 kg, Height= 1.52 cm, BMI=18 kg/m2

• HEENT: pink palpebral conjunctivae,

anicteric sclerae, (-) TPC (-) enlarged

tonsils

• Neck: supple, (-) CLAD, no neck vein

engorgement, (+) Left Carotid Bruit

• Chest/Lungs: SCE, no retractions, clear

breathsounds , no wheezes, no crackles

• Heart: Adynamic precordium, Apex beat at

5th ICS left midclavicular line, (-) heave, (-)

thrills, normal rate, regular rhythm, no

murmurs

• Abdomen: flat, NABS, soft, nontender, no

organomegaly, (+) bruit, left lower quadrant

Physical ExaminationNo discoloration

No swollen joints

Thigh and Calf atrophy L>R

Cold LLE > RLE

No hairs

No edema

2X3 cm Ulcer, plantar

aspect L foot, dry, pale

based, irregular border

gangrene, 5th digit, L foot

• Pulses: Regular rhythm

PULSES CAROTID BRACHIAL RADIAL FEMORAL POPLITEAL DPA PTA

RIGHT ++ ++ ++ + + 0 0

LEFT ++ Br ++ ++ + + 0 0

Neurologic Exam: oriented to 3 spheres, no cranial nerve deficitMotor: 5/5 both lower extremitiesSensory: intactReflexes: ++No babinski

Salient Features

• 81/F

• Diabetic

• Hypertensive

• Dyslipidemic

• Non-healing wound L 5th

digit for 11 months

• Leg pain at rest

• Limitation of activity

• Carotid bruit, L

• Left lower quadrant bruit

• cold left LE > right LE

• gangrene, 5th digit, L foot

• ulcer, lateral aspect L foot

• Gr 1 pulse femoral artery

& popliteal artery

• Absent pulses DPA, PTA

Question # 1

• Based on the salient features of our

patient, the most likely cause of L leg/foot

pain is:

A. Diabetic neuropathy

B. Venous claudication

C. Arthritis

D. Critical Limb Ischemia

Differential Diagnosis Condition Location of

Pain/Discomfort

CharacteristicDiscomfort

Onset Relativeto exercise

Effect of Rest

Effect of Body Position

Other Characteristics

Diabetic Neuropathy

Symmetricalleg, foot

Burning, shootingworst at night

None Not relieved by rest

Not relieved by dependency

Cutaneous hypersensitivity, decrease reflexes,decrease vibration

Venousclaudication

Entire leg, butusually worse in thigh and groin

Tight,bursting pain

After walking

Subsidesslowly

Relief speeded byelevation

History of iliofemoraldeep vein thrombosis, signs of venous congestion, edema

Differential Diagnosis

• Diabetic neuropathy

• Venous claudication

• Arthritis

• Critical Limb Ischemia

Differential Diagnosis Condition Location of

Pain/Discomfort

Effect of Rest

Diabetic Neuropathy

Symmetricalleg, foot

Burning, shootingworst at night

None Not relieved by rest

Not relieved by dependency

Cutaneous hypersensitivity, decrease reflexes,decrease vibration

Venousclaudication

Entire leg, butusually worse in thigh and groin

Tight,bursting pain

After walking

Subsidesslowly

Relief speeded byelevation

History of iliofemoraldeep vein thrombosis, signs of venous congestion, edema

• Arthritis

Differential DiagnosisCondition Location of

Pain/Discomfort

Effect of Rest

Arthritic, inflammatory processes

Foot, arch Aching pain After variable degree of exercise

Not quickly relieved(and may be present at rest)

May be relieved by not bearing weight

Variable, may relate to activity levelSwollen,tender joints

Critical Limb Ischemia

Distal part of foot or vicinity ofulcer or gangrenous toe

Intolerably severe

- Occurs at rest

Partially Relieved by dependent positionWorst when elevated

Cold exacerbates painPain worst at night

• Arthritis

Differential DiagnosisCondition Location of

Pain/Discomfort

Effect of Rest

Arthritic, inflammatory processes

Foot, arch Aching pain After variable degree of exercise

Not quickly relieved(and may be present at rest)

May be relieved by not bearing weight

Variable, may relate to activity level

Distal part of foot or vicinity ofulcer or gangrenous toe

Intolerably severe, worst at night

- Occurs at rest

Partially Relieved by dependent position

Worst when elevated

Cold exacerbates pain

Answer

D. Critical Limb Ischemia

Impression

L foot Ulcer, lateral aspect, probably ischemic in

origin, secondary to severe PAOD

Diabetes Mellitus type 2

Hypertension

Dyslipidemia

Underweight

Colon Cancer s/p colon resection

PTB IV

Question # 2

• Based on history and physical

examination, what is the level of arterial

occlusion?

A. Aorto-iliac

B. Popliteal Artery

C. Femoral artery

D. Tibial artery

location of the symptom often relates to the site of the most proximal stenosis

Aorta and iliac arteries: buttocks, hip & thigh

Femoral or popliteal artery: calf

Tibial & peroneal artery: ankle or foot

Braunwald’s Heart diseases 9th ed., 2011

Bruit LLQ

PULSES

FemoralArteryfe

Popliteal

Artery

Anterior Tibial

Artery

Postrior Tibial

Artery

Peroneal Artery

Dorsalis Pedis Artery

Answer

A. Aorto-iliac

Question # 3

Which among the following statements on

critical limb ischemia is/are correct:

A. typically with chronic ischemic pain at rest

B. with ischemic skin lesions such as ulcers

or gangrene

Question # 3

Which among the following statements on

critical limb ischemia is/are correct:

C. presence of symptoms for at least more

than 2 weeks

D. all of the above

Critical Limb Ischemia(CLI)

• manifestation of peripheral artery disease (PAD)

• typical chronic ischemic pain at rest

• ischemic skin lesions, either ulcers or gangrene

• Attributable to objectively proven arterial occlusive

disease

• Should only be used to describe patients who have

chronic ischemic disease, which is defined as the

presence of symptoms for more than 2 weeks

Norgren and Hiatt et al. TASC II guidelines 2008

Answer

• D. All of the above

Acute Limb Ischemia vs

ACUTE LIMB ISCHEMIA

• sudden decrease in limb

perfusion that could

threaten limb viability

• 5 P’s

CRITICAL LIMB ISCHEMIA

• chronic ischemic pain at

rest or ischemic skin

lesions, either ulcers or

gangrene

• chronic ischemic disease;

symptoms of more than 2

Fate of the Claudicant Over 5 Years (ACC/AHA Guidelines)

Natural History of athersclerotic lower extremity PAD syndromes

PAD population (50 years and over)Initial clinical presentation

Asymptomatic PAD20-50%

Other leg pain30-40%

Typical claudication10-35%

Critical limb ischemia1-3%

1-year outcomes

Alive with two limbs45%

Amputation30%

Mortality25%

5-year outcomes

CV morbidity & mortalityLimb mortality

Stable claudication70-80%

Worsening claudication10-20%

Non-fatal cardiovascular

event (MI or stroke)20%

Non-CV causes

25%CV causes

75%Amputation

(see CLI data)

Fate of the claudication over 5 years (adapted from ACC / AHA guidelines5). PAD – peripheral arterial disease; CLI – critical limb ischemia; CV –cardiovascular; MI – myocardial infarction.

Mortality10-15%

1-year outcomes

Alive with two limbs45%

Amputation30%

Mortality25%

Fate of the claudication over 5 years (adapted from ACC / AHA guidelines

Question # 4

Ulcers due to arterial occlusive disease typically have:

A. irregular borders, severely painful & usually involve the tips of the toes or develop at sites of pressure

B. irregular borders, mildly painful, pink base with granulation tissue & localizes near the medial malleolus

Question # 4

Ulcers due to arterial occlusive disease typically have:

C. multiple in number & located in the lower third of leg & severely painful

D. it is often deep, frequently infected & located in the sole of the foot & usually not painful

Differential Diagnosis of

Foot and Leg Ulcers

Origin Cause Location Pain Appearance Role of revascularization

Arterial Severe PAD, Buerger’s disease

Toes, foot, ankle, pressure sites

Severe Various shape, irregular borders, pale base, dry

Impor-tant

Venous Venous Insufficiency

Malleolar, esp medial

Mild Irregular, pink base, moist

Differential Diagnosis of

Foot and Leg UlcersOrigin Cause Location Pain Appearance Role of

revascularization

Neuro-pathic

Neuropathy from diabetes, vitamin deficiency, etc

Foot/plantar surface (weight bearing), associated deformity

None Surrounding callus, oftendeep, infected

Neuro-ischemic

Diabetic neuropathy + ischemia

Locations common to both ischemic and neuroischemic as arterial

Reduced due to neuropathy

As arterial As arterial

Answer

A. irregular borders and usually involve the

tips of the toes or the heel of the foot or

develop at sites of pressure and severely

painful

Arterial Ulcer

Neuropathic Ulcer

Venous Ulcer

Dependent Rubor

Pallor on Leg

Elevation

Ischemic Ulcer

Question # 5

• According to Fontaine classification of peripheral arterial disease, presence of ulcer/ gangrene is classified as:

A. III

B. II A

C. II B

Rutherford, et.al. JVS, 1997

Fontaine’s Stages Rutherford

GRADE CATEGORY CLINICAL DESCRIPTION

I 0 Asymptomatic

1 Mild claudication

2 Moderate

3 Severe

II 4 Ischemic rest pain

5 Minor tissue lost: non-healing, ulcer, focal gangrene

III 6 Major tissue loss extending above transmetatarsal level,

functional loss, foot not salvageable

STAGE SYMPTOMS

I Asymptomatic

IIA Claudication > 200 m

IIB Claudication < 200 m

III Rest / nocturnal pain

IV Necrosis, gangrene

Answer

Question # 6

Which among the following statement is correct:

A. Resting ABI is a class 2 recommendation in

establishing the diagnosis of lower extremity PAD

B. ABI should be measured in both legs in all

new patients with PAD of any severity to confirm

the diagnosis of lower extremity PAD & establish

a baseline

ACC/AHA Guidelines on

lower extremity PAD

Class 1C recommendation

The resting ABI should be used to establish

the lower extremity PAD diagnosis in

patients with suspected lower extremity PAD

Class 1B recommendation

The ABI should be measured in both legs in

all new patients with PAD of any severity to

confirm the diagnosis of lower extremity PAD

and establish a baseline

ACC/AHA Guidelines on

lower extremity PAD

Ankle Brachial Index

• Most cost-effective tool for lower extremity

PAD detection*

• < 0.90: abnormal

90% to 95% sensitive & 98% to 100%

specific: angiographically verified peripheral

arterial stenosis**

• leg claudication: ABI 0.5 to 0.8**

• critical limb ischemia: ABI of <0.5**

**Braunwald Heart Diseases 9th ed, 2011

*ACC/AHA 2005 Guidelines on PAD

Segmental

Pressures

and ABI

results

Upper thigh

Above Knee

Below Knee

Interpretation: severe

PAD, both LE

Segmental Pressure

• Class 1B recommendation

• useful to establish lower extremity PAD

diagnosis when anatomic localization of

lower extremity PAD is required to create a

therapeutic plan

ACC/AHA 2005 Guidelines on PAD

Segmental

Pressures

and ABI

results

Upper thigh

Above Knee

Below Knee

Interpretation: severe

PAD, both LE

Toe-Brachial Index

• Class 1B recommendation

• used to establish the lower extremity PAD

diagnosis in patients in whom lower

extremity PAD is clinically suspected but in

whom the ABI test is not reliable due to

noncompressible vessels

Brachial

Question # 7

• What is the gold standard diagnostic tool

for the diagnosis of PAD?

A. CTA

B. MRA

C. Contrast Angiography

D. Duplex Scan

Answer

C. Contrast angiography

– “gold standard” for defining both normal

vascular anatomy and vascular pathology

– most readily available and widely used

imaging technique

– dominant diagnostic tool used to stratify

patients prior to intervention

Duplex Scan

Class I A recommendation

• useful to diagnose anatomic location and

degree of stenosis of PAD

• routine surveillance after femoral-popliteal

or femoral-tibial- pedal bypass with a

venous conduit

Peripheral Arterial Duplex Scan

TASC II Guidelines PAD

• If a patient qualifies for invasive

therapy, angiography will, ultimately,

be required in almost all elective

cases, preoperatively for surgical

reconstruction and before or during

catheter-based interventions

FEMORAL ANGIOGRAM

Question # 8

• According to TASC II guidelines, the

aorto-iliac lesion of this patient is classified

A. Type A

B. Type B

C. Type C

D. Type D

TASC Classification of Aorto-iliac Lesions

• Type A

• Type B

• Type C

• Type D

Question

A. Type A

MANAGEMENT OF CLI

Goals of Treatment

• Relieve ischemic pain

• Heal (neuro) ischemic ulcers

• Prevent limb loss

• Improve patient function and quality of life

• Prolong survival

Management of CLI

• Cardiovascular risk modification

• Early referral for Revascularization

• Supervised Exercise Rehabilitation

• Pharmacotherapy

• Foot Care

• Multidisciplinary Care

Risk Modification

Grade A Recommendation

CLI patients should have

aggressive modification

of their cardiovascular

risk factors

TASC II Guidelines PAD,

Question # 9

What is the optimal treatment for CLI?

A. Revascularization

B. Medical treatment

C. Both

D. None of the above

Answer

Grade B Recommendation

Revascularization is the optimal

treatment for patients with CLI

REVASCULARIZATION

Recommendation

Patients with CLI should be referred to a

vascular specialist early in the course of

their disease to plan for revascularization

options

Grade C

Options in Limb Revascularization

Endovascular techniques:

1. Balloon angioplasty

2. Stents

3. Stent grafts

Surgical options:

1. Autogenous or synthetic bypass

2. Endarterectomy

3. Intraoperative hybrid procedures

TASC II Guidelines PAD, 2008

Revascularization

The success of a revascularization procedure primarily

depends upon:

• Extent of the disease in the subjacent arterial tree

• Degree of systemic disease

• Type of procedure performed

Question: True or False

• Open surgery is preferred over

endovascular revascularization even they

have equivalent short- and long-term

symptomatic improvement.

A. True

B. False

Recommendation

In a situation where endovascular

revascularization and open surgery are

associated with equivalent short- and long-

term symptomatic improvement,

endovascular techniques should be used

Grade B

Question # 10

• Based on the TASC II guidelines, the

recommended treatment in type C aorto-

iliac lesion is:

A. Surgery, in high risk patients

B. Endovascular

C. Surgery, in good risk patients

D. None of the above

TASC Recommendation for treatment of

Aortoiliac Lesions

TASC A lesion: Endovascular therapy

TASC D lesion: Surgery

Grade C

TASC Recommendation for treatment of

Aortoiliac Lesions

TASC B lesions: Endovascular Treatment

TASC C lesions: Surgery for good-risk patients

The patient’s co-morbidities, fully informed patient

preference and the local operator’s long-term success

rates must be considered

Grade C

Answer

C. Surgery, in good risk patients

Procedure done

Angioplasty and stenting by kissing

technique of bilateral common iliac artery

Limb Salvage

• Preservation of some or all of the foot

• Should take place after a revascularization

• Waiting period: at least 3 days

• Two categories:

1. Amputation of some part of the foot

2. Debridement of the wounds, including

excision of bone

Management of Ulcer

• Restoration of perfusion

• Local ulcer care and

pressure relief

• Treatment of infection

Course in the ward

• Daily wound care

• Antibiotics

• Debridement and disarticulation of the 5th

digit of the left foot

Post-op:

moist, non foul-smelling

wound debridement site

with beginning granulations

• Relief of leg pain

Clinical Surveillance post

Revascularization

Recommendation

• Patients undergoing aortoiliac and

infrainguinal transluminal angioplasty for

lower extremity revascularization should

be entered into a surveillance program.

• Surveillance programs should be

performed in the immediate post-PTA

period and at intervals for at least 2 years.

ACC/AHA Guidelines on PAD, 2005

Recommendation on Antiplatelet drugs as

adjuvant pharmacotheraphy after

revascularization

Antiplatelet therapy should be started

preoperatively and continued as adjuvant

pharmacotherapy after an endovascular or

surgical procedure

Unless subsequently contraindicated, this

should be continued indefinitely

Grade A

Exercise Rehabilitation

Supervised exercise should be made available as part of the initial treatment for all patients with peripheral arterial disease

The most effective programs employ treadmill of track walking that is of sufficient intensity to bring on claudication, followed by rest, over the course

of a 30-60 minute session

Exercise sessions are typically conducted three times a week for 3 months

Grade A

Potential Favorable Effects of Exercise Training

↑ Nitric oxide synthase

↑ Prostacyclin

↓ Free Radical

↑ Vascular Endothelial Growth Factor

↑ Muscle oxidative activity

↑ Muscle enzyme activity

↑ Muscle acylcarnitine homeostasis

↓ Blood viscosity ↑ RBC filterability

↓ RBC aggregation

Exercise Training

Improved endothelial function

Reduced Inflammation

Possible vascular angiogenesis

Improved muscle metabolism

Improved hemorrheology

N Eng J Med. 2002;347(24):1941-1951

Pharmacotherapy• Vasodilator Drugs

– Cilostazol 100mg BID X 3-6 mos (Class I LOE: A)

• Hemorrheologic Agents

– Pentoxifyiline (Class III LOE: B)

• Parenteral Prostaglandins

– Beraprost & Iloprost (Class IIb LOE A)

• Antiplatelet

– Aspirin and Clopidogrel (Class I LOE A)

• Statins (Class I LOE B)

• Angiogenic Growth Factors (Class IIb LOE C)

Antiplateletactivity

Antithromboticactivity

Producesvasodilation

Mildly increasesheart rate

Increasesblood flow

IncreasesHDL-C

Decreasestriglycerides

In vitro inhibition of vascular smooth

muscle cellsCilostazol

Pharmacologic effects of CilostazolIncreased intracellular cAMP

Recommendation

3- to 6-month course of Cilostazol (100

mg orally 2 times per day) should be first-line

pharmacotherapy for patients with lower

extremity PAD and intermittent claudication

Class I

Level of evidence A

Foot Care

• Feet should be kept clean

• Moisturizing lotion

• Well-fitted shoes

• Regular feet inspection

• Avoid Elastic support stockings

Discharge Medications

• ASA 80 mg/tab 1 tab OD

• Cilostazol 100mg/tab 1 tab BID

• Atorvastatin 20mg/tab ½ tab OD

• Telmisartan 40mg/tab 1 ta OD

• Diltiazem 90mg/tab 1tab BID

• Sitagliptin/Metformin 50/500mg 1tab BID

• Glimeperide 2mg/tab ½ tab OD

Follow-up

1 day post-op 1 month post-op

Follow-up

2 months post-op 3 months post-op

Follow-up

4 months post-op

Summary

• CLI is a clinical diagnosis but should be

supported by objective tests

• Early identification of patients at risk for

CLI and early management should be

• Patient education and close follow-up after

revascularization are necessary

THANK YOU

Interactive Case Presentation Happy Foot

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