Peripheral Arterial Disease: A Case Report From the Henry Ford Hospital

Abstract

A.T. is a 65-year-old black female with claudication secondary to peripheral arterial disease (PAD). She has a history of coronary artery disease, myocardial infarction, heart failure, endarterectomy, hypertension, hyperlipidemia, type 1 diabetes mellitus, and asthma.She was referred to the Division of Vascular Surgery at Henry Ford Hospital complaining of fatigue and heaviness in her lower thighs and calves during walking. Resting ankle-brachial index (ABI) was 0.50 and 0.70 at the right and left dorsalis pedis, respectively. She was prescribed cilostazol and encouraged to "…walk through the pain as much as possible."Due to worsening claudication, A.T. underwent an abdominal aortogram with arteriogram of the lower extremities. Results showed aortoiliac disease with multiple stenoses of varying degrees. Areas of calcification were noted from the lower aorta and iliac artery to the anterior tibial artery affecting both the left and right limbs.Results from a stress echocardiogram showed cardiac wall motion abnormalities consistent with exercise-induced ischemia. She exercised for 5.8 minutes on the Bruce protocol, limited by general fatigue. The electrocardiogram displayed left bundle branch block, resting ejection fraction was 40%, peak blood pressure was 160/80 mmHg, and peak heart rate was 120 b·min −1 . No symptoms were reported. Her medications are cilostazol, carvedilol, amlodipine, isosorbide dinitrate, clopidogrel, simvastatin, potassium, triamcinolone, ipratropium, and pirbuterol.She began supervised exercise training in cardiac rehabilitation following a hospitalization for angina. At rest her blood pressure was 120/50 mmHg, heart rate was 79 b·min −1 , blood glucose was 6.89 mmol·L −1 (266 mg·dL −1 ) and her HbA1c was 8.0%. Her initial exercise sessions were limited by bilateral claudication of her thighs and calves. Moderate pain occurred after 9 minutes of walking on day 1. A painrest walking program was initiated and followed for 12 weeks. She then joined the Henry Ford PREVENT program, which provides patients with a low-cost, long-term supervised exercise environment.She now exercises at least 3 d·wk −1 for 60 minutes each session. She splits her exercise time between a seated stepper and a treadmill. On most days she is now able to walk 30 continuous minutes without limiting claudication pain. DISCUSSIONThe natural history of arteriosclerosis involves an intimal plaque that progressively develops until it eventually causes a significant flow limiting occlusion of the vessel and reduction of blood supply relative to demand. Arteriosclerosis is a systemic disorder affecting the major circulations, with the intimal plaque occurring segmentally in multiple locations. When the plaque occurs in the distal aorta or in the arteries of the lower extremities, it is referred to as PAD. EpidemiologyMore than 8 million individuals in the United States above the age of 40 are estimated to have PAD (1). The prevalence of PAD per ABI is 4.3% in persons older than 40 years and up (2) and 29% in those 70 years and o...

Peripheral artery disease in patient with end-stage renal disease on regular hemodialysis: a case report

“…The ABI examination is performed by measuring the systolic blood pressure in each ankle and dividing it with the greater value of systolic blood pressure between the left and right arm (brachial artery). 13 The resting ABI assessment in this patient's right leg was 0.84, so the patient could be diagnosed with PAD clinically. Despite, ABI on the left leg slightly decrease (0.92), the patient did not complain of pain or any abnormality on the left leg.…”

“…Hypertension and hyperlipidemia are also risk factors for PAD. 8,13 The patient, in this case, had a history of diabetes mellitus for five years, chronic renal failure for two years, and hypertension which made the patient more susceptible to PAD.…”

“…Pulse examination should be performed on several arteries, including the femoral, popliteal, dorsalis pedis, and posterior tibial arteries. 13,15 This patient had weaker pulses in the dorsalis pedis and popliteal arteries of the right leg than in the left leg, based on palpation.…”

“…Some of the reasons that cause this condition are the presence of diabetic neuropathy which can mask symptoms, or not reporting symptoms due to avoiding activities that trigger pain. 13,15 Physical examination should focus on palpation of lower extremity pulses and auscultation for vascular murmurs. 11,15 Physical examination may reveal paresthesia, ulceration, numbness, and gangrene at an advanced stage with multiple lesions or redness with swelling, shiny skin, hair loss, and muscle atrophy on the lower extremity.…”

Feasibility of Blood Flow Restriction Resistance Exercise for Patients with Intermittent Claudication

“…The potential mechanisms of exercise to improve claudication symptoms are not completely clear. Virtually all trials that have evaluated the importance of exercise training in patients with IC have exhibited an increase in exercise tolerance (Levine, 2018), but it is noted that exercise has not shown to affect ABPI and haemodynamics (Paramenter et al, 2010). A variety of adaptive mechanisms in the lower limb muscles have been suggested, including improved endothelial vasodilator function, skeletal muscle mitochondrial metabolism, muscle architecture, and muscle strength and endurance (Harwood, Cayton, et al, 2016).…”