Peripheral Vascular Disease In Lower Limb

PERIPHERAL VASCULAR DISEASE IN LOWER LIMB

BRIEF ARTERIAL ANATOMY OF LOWER LIMB

Case 1

  • Navin Shah 68/M
  • Came with complaints of blackening over left little toe since 2 months
  • He has been to 4 other hospitals where he could not get the satisfactory treatment and was advised lower limb amputation
  • We have taken up the case and after discussions and meticulous planning with the help of available diagnostics and set off for the management
  • H/o DM (Diabetes) / HTN (Hypertension) for the past 25 years
  • H/o CAD-TVD (Coronary artery disease) on medical management
  • H/o chronic smoking +
  • Peripheral angiogram was done which showed ATA/PERONEAL ARTERY total occlusion, Distal Percutaneous Transluminal Angioplasty (PTA) 90% stenosis.
  • He was first treated with POBA and angioplasty (Plain Old Balloon Angioplasty) to ATA / PTA and PERONEAL artery.
  • Subsequently with limited amputation of just the little toe we are able to achieve our goal of limb salvage surgery.

Case 2

  • T Rama Rao 61/m
  • Came with complaints of ulcer over left foot for over 2 months. He is known case of heart disease undergoing treatment
  • History of Diabetes since 25 years
  • Evaluated – complete block of main artery supplying lower limb
  • Treatment – PTA (Percutaneous Transluminal Angioplasty) with 3 stents
  • Debridement and regular dressings has heeled the wound completely

Case 3

  • Prathap Reddy 71/M
  • k/c/o CAD (Coronary Artery Disease)
  • History of HTN + (Hypertension) / DM + (Diabetes)
  • C/o Blackish discoloration of left little toe
  • Peripheral angiogram shows left ATA and PTA – 99% stenosis
  • Treatment – Amputation of left 4th,5th toes followed by

BASICS

  • In peripheral arterial disease there is a decreased or total loss of blood supply to the peripheries (most commonly affects lower limbs)
  • Due to
    • Embolism
    • Atherosclerosis, thrombosis
    • Trauma
    • Complications of peripheral aneurysm

RISK FACTORS

  • Age
  • Gender – Male common
  • Obesity
  • Family history
  • Diabetes
  • Smoking
  • Hypertension
  • Dyslipidemia
  • Hyperhomocysteinemia
  • Race (Asian / Hispanic / black vs white)

STATISTICS

  • Approximately 12% of the adult population has PAD, almost 20% of adults older than 70 years have PAD
  • A new analysis published by THE SAGE GROUP concludes that atherosclerotic peripheral arterial disease (PAD) afflicts over 20 million in India
  • Once PAD has progressed to CLI (Chronic Limb Ischemia), the risks of limb loss and mortality increase. At six months approximately 20% of those with CLI will die; another 40% will experience amputation.
  • Diabetics represent 60% to 80% of CLI patients, we believe that India may unfortunately be on the path to becoming the Critical Limb Ischemia Capital

WHY MORE COVERAGE

  • Under diagnosed, undertreated, and poorly understood even by the physicians and much more common than thought considering the lifestyle and the rise of share of the non communicable diseases like hypertension and diabetes.
  • The diagnosis of PAD should not be overlooked for 2 important reasons. First, patients with PAD may experience many problems, such as claudication, ischemic rest pain, ischemic ulcerations, repeated hospitalizations, revascularizations, and limb loss. These lead to a poor quality of life and a high rate of depression
  • Cardiovascular death and have a higher rate of all-cause mortality compared with patients without PAD.

TREATMENT EARLIER

  • Amputation if wound does not heal and necrosis due to compromised blood supply revised amputation resulting in high morbidity and mortality rates
  • Due to new modalities for diagnosis such as colour doppler, CT angio, DSA, MRA and new interventions like peripheral stenting with advanced stents
  • Level of obstructed supply can be made and appropriate intervention can be done

HOW WE DO IT

  • Depending on the stage of presentation
  • Non healing ulcer – debridement if needed after endovascular technique
  • Gangrene – Infected – Amputate to reduce sepsis – endovascular technique
  • Non infected – endovascular technique – amputate
  • Vasodilators to increase blood supply and anticoagulants and anti platelets for stent patency and anti diabetics, anti hyper lipidemics and anti hypertensives depending on the risk factors and regular dressings and wound care.
  • The goals of therapy are to improve symptoms and thus quality of life and to decrease the cardiovascular event rate (myocardial infarction, stroke, cardiovascular death)
  • Accomplished by establishing a
    • Supervised exercise program and
    • Administering cilostazol or performing a revascularization procedure if medical therapy is ineffective.
    • A comprehensive program of cardiovascular risk modification (discontinuation of tobacco use and control of lipids, blood pressure, and diabetes) will help to prevent the latter

STENT

  • Stent placement is typically used when residual stenosis after PTA is 30% or greater
  • Primary stent placement has become a viable alternative for treating ulcerative lesions that may potentially be the source for embolization
  • Several clinical studies have demonstrated the significant improvements of the new generation of nitinol stents for the SFA lesions: the German Multicenter Experience, the Mewissen trial, the BLASTER Trial, and the SIROCCO trial

TAKE HOME MESSAGE

Watch out for

  • Tingling sensation in the legs
  • Pain after walking a certain amount distance
  • Sudden rest pain
  • Ulcerations
  • Blackening
  • Especially on the background of the above said risk factors
  • Better to get evaluated about the limb and the doctor will decide if your heart status also needs to get evaluated 

MOTTOS

  • Salvaging your precious limb
  • Adding miles to your walk

Pain in the surgical/trauma

1. What is pain?

Pain is an unpleasant physical and emotional response to actual or potential tissue damage or described in terms of such damage.

It is a protective response which ensures that an injured part of the body is carefully handled and further damage is prevented.

2. Why do we feel pain?

There are nerve endings distributed all over our body- from the skin to the intestines. These get activated in response to injuries from varied mechanisms like cuts and bruises, deep pressure, burns, extreme cold etc. Upon activation, signals are sent by the nerve endings to the brain and pain is perceived.

 

3. Why is it important to reduce pain?

Control of pain leads to a better life -Pain is unpleasant. It leads to emotional responses like depression and anger. It imposes a financial burden on the individual as well as society not only because of the expenses of treatment but also because there is loss of productive work-hours in the affected population. Long-lasting pain affects day-to-day functioning. People with pain tend to handle that body part carefully leading to stiffening of the joints and loss of muscle mass due to disuse. The stress leads to lack of control of blood pressure and blood sugar, sleeplessness, increase in acidity and body weight.

In patients undergoing surgery, pain relief leads to early recovery which means the patient walks sooner (Decreasing the chances of blood clots forming in the legs and travelling to the heart). He has better control of blood pressure and blood sugars due to decrease in stress levels and is less prone to stress-related complications like heart failure. All this leads to earlier discharge from the hospital.

 

4. How is pain classified?

There are various ways to classify pain:

There can be more than one type of pain in a patient due to more than one cause. This is important to know because the treatment changes with the cause/type/duration.

  • Based on the duration it can be acute ie immediate or sudden, usually lasting from 3 to 6 months or chronic ie long-lasting-more than 6 months or acute-on-chronic ie sudden pain superimposed upon a pre-existing pain.
  • Based on the site of origin it can be Somatic ie arising from the skin/Bones/muscles or Visceral ie from the internal organs like the intestine or Uterus.
  • Based on the cause of pain it can be Neuropathic ie arising from nerves which are injured or Inflammatory ie due to chemicals released after injury.

 

4. What are the common means of reducing pain?

Pain can be mitigated by non invasive or invasive means. Non invasive methods include oral medicines (Aspirin, Paracetamol, morphine etc.) Hot fomentation, cold compresses, physiotherapy, yoga and so on.

Invasive methods include pain killer injections either into the muscles or veins and more recently blocking nerves causing pain with anaesthetic drugs. Each method has its advantages and disadvantages.

Medicines which are called NSAIDS ( Nonsteroidal anti-inflammatory drugs) include Ibuprofen and Diclofenac. They act by decreasing the inflammation at the site of the pain. But when taken for a prolonged duration they might cause damage to the kidneys. They should also not be taken by those suffering from asthma or heart/bleeding problems.

Opiod drugs like Morphine, while very very effective, are the leading cause of addiction in the US and active research is ongoing to find alternate means of pain relief especially in the acute setting of trauma or surgery.

 

 

5. My friend recently had an accident and fractured his thigh bone and has to undergo surgery. What modes of pain relief can she be given?

After an accident there are various factors to take into consideration before pain relief methods can be planned. The treatment differs for young people with no other health issues vis-a-vis older persons with say high blood pressure or diabetes or kidney failure. It will also change with the extent and region of injury, ensuing blood loss, ability of the patient to breathe adequately, neurological status (Drowsy/conscious) and the expertise of the medical personnel.

In all cases no one method is considered superior or enough by itself. A multi-prong approach to pain relief ranging from oral/i.v medicines to blocking the nerves carrying pain from the injured area (Nerve block) helps in lessening the side effects, complications and costs involved.

 

6. What is a nerve block?

A nerve block involves deposition of local anaesthetic drugs near a nerve or a bundle of nerves to temporarily stop them from working. This cuts off pain transmission at the very first step.

For example this patient with a fracture of the thigh bone will have severe pain upon any sort of movement and may be taken up for surgery only after a few days especially if he has other problems like being on blood-thinning medicines or uncontrolled diabetes. In the meantime she will need a Femoral nerve block along with other pain medication. The femoral nerve is present on the front of the thigh near the groin.

 

 

7. How is the nerve block given?

Before giving the nerve block we ensure that the nerve itself is not injured from the accident by testing sensation and muscle movement. If there is any doubt we do not proceed with the block and give alternate means of pain relief.

Nerve blocks are given by qualified Anaesthesia doctors. All nerves in the body have more or less a constant location in humans. They can be identified by means of landmarks eg the Femoral nerve is close to the major artery in the groin whose pulsations are easily felt.

Sometimes the Anaesthetist might use a needle through which very small current pulses are given in order to locate the nerve. These pulses do not cause pain and are felt more like vibrations. When the needle is close to the nerve, the muscles supplied by the nerve show contraction. With the femoral nerve the muscles on the front of the thigh will move. At this point all the drug is given.

Another precise way of identifying the nerve is by using ultrasound where the pulsating artery and the nerve next to it are visible on the screen.

After the drug is injected the patient will get pain relief in 5-10 minutes. If prolonged pain relief needs to be given we leave small tubes called catheters next to the nerves and give a constant supply of the numbing medicine through syringe pumps for as long as needed (Commonly 3-4 days).

 

8. Will I have pain when the nerve block is given?

No, the doctor will first give a small numbing injection on the skin before using the other needle.

 

9. How soon will I get pain relief and how much of relief can I expect? Is there a way to measure pain?

Pain relief usually starts within 10 minutes and depends on the concentration of the drug given. It might take upto an hour for maximum relief.

The extent of relief varies from tolerable pain to sometimes complete relief.

The level of pain perceived is very individual-specific. Some people can bear the pain after Hip replacements and some may cry holy murder while an i.v cannula is being placed.
Most commonly the health care provider uses a visual analogue scale (VAS) to note down the pain level being experienced. This is a scale where the facial expression of the patient is assigned a number ranging from 0 to 10 . Here 0 means a happy face and 10 denotes extreme crying. Similarly, the health care provider or nurse might ask the patient to give a number to the pain being experienced (Numerical scale). Again 0 means no pain and 10 is the worst pain imaginable. The aim for us is usually to bring the pain down to less than 3 denoting mild/tolerable pain.

 

10. Will there be any side effects/complications of the nerve block?

Like any procedure done on the human body there are always chances of complications during nerve blocks. When done by expert hands minor complications are infrequent and major complications rare.
These range from failed blocks with no pain relief, injury to blood vessels/lungs/nerves/other organs, temporary weakness of the muscles supplied by the nerve and very rarely injection of the drug into blood vessels leading to Local Anaesthetic Systemic Toxicity.

The doctors giving the nerve blocks are trained to prevent and recognise such complications. They will use full monitoring like Blood pressure, ECG and oxygen saturation in the blood before, during and for 3 to 4 hours after the procedure. You will need to be admitted in the hospital for that duration.

 

11. Why should I undergo a nerve block when there are other means of pain relief?

Different degrees of pain need different methods of treatment.
A simple headache after a sleepless night might subside after an oral painkiller. Pain due to falling on the ground while running might need an injection into your arm/buttock. A fracture pain or one after a surgery will need oral medicines, injectable pain killers like i.v Morphine and yet not lead to adequate relief. It is such pain which benefits from nerve blocks.
In the surgical setting physiotherapy and active movements become easier and less painful if continuous pain relief is given with nerve block catheters. Our patients undergoing total knee replacement generally walk within 4 hours of surgery.

Further most analgesics (Pain-killers) come with their own respective set of side effects. Many of them cannot be used if you have a history of poor kidney function/ Asthma/ Heart attacks/Bleeding tendencies. They can lead to nausea, dizziness, retention of Urine, constipation, breathing difficulty, drowsiness etc.

In the trauma/surgical setting we need to use all methods in order to attack every step of the pain pathway in the body and minimise the overall dose of individual drugs. So you will be getting oral medicines, i.v injections as well as nerve blocks. These have an additive effect and individual doses of each medicine reduce drastically.

 

12. How long does pain last after surgery?

After any surgery maximum pain is felt during the first 3 to 4 days and this gradually decreases over a period of the next 7 days.

 

13. My father has fractured his ribs and finds it difficult to breathe without pain. He cannot afford to take long leave from work. Can nerve blocks help?

Yes. Rib injuries prevent patients from taking deep breathes due to pain. This causes gradual collapse of the small airways in the lungs. The ensuing inadequacy of oxygen in the body and chances of developing Pneumonia will require hospitalisation.

Such patients can be helped by the placement of Erector Spinae or Serratus Anterior plane blocks. A small catheter will be placed in between the muscles of the chest wall or back and a continuous infusion of local anaesthetic medicine will be given from a portable infusion pump which can be taken home. Deep breathing exercises are thus possible and prevent deterioration of the lung and loss of work-hours.

The infusion pumps will contain medicine for upto 48 hours and you will need to get it refilled at the hospital. A week of such treatment will give enough time for the body to heal.

Pulmonologist in Hyderabad

THIRD HAND SMOKE – KEEP IT OUT

The common belief is that the person who smokes is the one only affected by smoking. However, that’s not true. Over time we have understood that children and non-smoking adults around a smoker might also have an adverse effect of smoking. Risks due to third-hand smoke can vary from recurrent asthma attacks to cancer.

Smokers are of 3 types depending on type of exposure

  • FIRST HAND SMOKERS: Smokers himself
  • SECOND HAND SMOKERS: Those who inhale a mixture of exhaled smoke and other substances left by the smoldering end of the cigarette
  • THIRD HAND SMOKERS: Those exposed to toxins residues that cling to different indoor surfaces.

 

Third Hand Smoke

Third-hand smoke is residual nicotine, tar, and other carcinogenic (cancer-causing) toxins left on indoor surfaces by tobacco smoke.

It clings on to clothes, furniture, drapes, walls, bedding, carpets and lingers on surfaces long after smoking has stopped which accumulates on the surfaces over a period of time. Non-smokers are exposed to these chemical toxins when they inhale, swallow or touch these surfaces.

 

Health Hazard due to third hand smoke

It may cause illnesses such as heart disease, cancer, chronic obstructive pulmonary diseases (COPD), ear infections in a third-hand smoker is equal to that in a smoker.

Infants and children are at the highest risk of health hazards. Children have poor brain dependent and frequent “Asthama Attacks”.

Research at Lawrence Berkeley National Laboratory found that baby mouse exposed to clothes and third-hand smoke were underweight and had negative effects on red cell production.

Prevention

  1. The only way to protect non-smokers from Third-hand smoke is to create a smoke-free environment away from children, pets and those at risk.
  2. To remove residues from hard surfaces, fabrics, and upholstery must be regularly cleaned professionally.
  3. Simply airing rooms via air conditioners and fans do not eliminate third-hand smoke. The only way to completely protect is to quit.

 

Early detection & treatment for Diabetes

Diabetes is a complex, chronic illness which requires continuous medical care with multifactorial risk-reduction strategies beyond glycemic control. Ongoing patient education on self- management and support are critical to preventing acute complications and reducing the risk of long-term complications.

Criteria for the diagnosis of Diabetes:

  • Fasting Plasma Glucose ≥126 mg/dL. Fasting is defined as no caloric intake for at least 8 hours.* OR
  • 2-h Plasma Glucose ≥200 mg/dL during Oral Glucose Tolerance Test. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.*OR
  • Glycosylated hemoglobin HbA1C ≥6.5%.* OR
  • In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL

In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples.

Diabetes can be classified into the following general categories:

  1. Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency)
  2. Type 2 diabetes (due to a progressive loss of β-cell insulin secretion frequently on the background of insulin resistance)
  3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation)
  4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such as with steroid use)

 

If untreated or inadequately treated, it may lead to complications like cardiovascular diseases (heart attack), stroke (cerebrovascular accident), diabetic retinopathy and visual loss, foot ulcers, diabetic neuropathy, diabetic nephropathy with protein loss and chronic kidney disease.

Comprehensive care for a diabetic patient involves control of blood glucose, cholesterol levels, blood pressure, maintenance of ideal body weight and risk assessment for cardiovascular and peripheral vascular diseases. Regular eye check-up, foot care, self-monitoring of blood glucose, and ability to recognize hypoglycemic symptoms and take remedial measures is of paramount importance. Every person with diabetes need to know the correct technique to self- administer insulin, basics regarding anti-diabetic oral medications, and should be provided with an individualized diabetic diet plan.

 

With this comprehensive approach, a good control of diabetes can be achieved and the person can lead a productive life like any other individual.

HYDERABAD OSTEOTOMY COURSE

Dr Udai Prakash is organising THE HYDERABAD OSTEOTOMY COURSE, on 2nd June at Taj Deccan to help knee surgeons share their wealth of experience in all aspects of knee osteotomy surgery, rehabilitation and dealing with complications.

This course discussions will help upcoming and established knee surgeons with the aim of passing on the benefits to patients.

Osteotomy means “cutting of bone in such a way so as to re-align it in its correct position”. There are many instances when a surgeon may offer an osteotomy as a course of treatment. For example:

  • Bow legs or knock knees in children and young adults
  • Straightening of man-united fractures
  • Alleviate pain in arthritis of joint
  • Correction of mal-tracking or recurrent dislocation of patella
  • Correction of various congenital deformities etc

There has been a resurgence of interest in the use of osteotomy for alleviating pain in the knee due to arthritis. This procedure avoids or postpones knee replacement surgery or simply can be thought of as an alternative to knee replacement.

Many young adults also have deformities in their legs which could give them an awkward gait as well as prevent them from taking part in active sports. These deformities can also make them very socially conscious about the appearance of their legs. Many young girls with deformities are brought to us by parents anxious about their marriage.

The course has a mix of national, international and local faculty with a wealth of experience in this technique. There will be a live surgical demonstration and series of talks and discussions.

The course is targeted towards the young knee surgeon keen to develop an interest in this technique. Experienced surgeons will also gain from this course and will have a chance to network and learn the nuances of this surgery from experts.

 For More Details : Click Here

 

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