Case Scenario

Dr. Adam Fendius, BSc (Hons), MBBS, FRCA, DiplMC (RCSED), DipHEP

Arthur, a 64-year-old man, who is an obese, heavy smoker with diabetes, has a history of gradually increasing calf pain on walking. He had CABG surgery 6 years ago. Over the last 2 weeks, he has noticed the pain occurring more readily. The pain disappears after he has stopped walking for a few minutes, but resumes after he has walked even a short distance.

What questions would you like to ask?

It is important to determine the exact nature of the pain, as this will point to the cause, and therefore, potential treatment. You should ask whether the pain is characterized by tightness, burning, stinging "like pins and needles," electric shock, or dull ache. Also, you need to determine whether the pain occurs only when he walks or even when he rests, and whether he has any back pain, or pain in his hip or knee? Also, is it related to position of the limb at rest or how quickly he walks? You could also administer the "Edinburgh Claudication Questionnaire."

What is your differential diagnosis?

For proper pain management in this setting, diagnosis is important, as there can be several causes of lower limb pain while walking. These include nerve entrapment syndromes such as sciatica and spinal canal stenosis, as well as deep vein thrombosis, musculoskeletal injury, and intermittent claudication due to peripheral vascular disease. The diagnosis might be confirmed by Doppler sonography of iliac and lower limb arteries.

Arthur tells you that the pain only comes when he walks and does not interfere with his sleep. He only has it in his calf and it feels like a "dull, aching, tightness." It is worse when he has to climb a hill or in cold weather. You decide this is most likely to be an ischemic pain, related to peripheral vascular disease, for which he has multiple risk factors.

How are you going to manage his current pain?

Primary intervention should include lifestyle advice to prevent deterioration of the intermittent claudication to ischemic rest pain and critical limb ischemia. He should be advised to stop smoking and you should optimize his diabetic control. He should attempt to lose weight through diet and exercise. In fact, he does not need to walk to do exercise and instead may use an arm exercise machine. Low-dose antiplatelet therapy such as aspirin or clopidogrel should be considered, and antihypertensive medications should be reviewed for optimal therapy. Cilostazol has also been shown to improve claudication pain. The use of pentoxyfilline and inositol is controversial. Evidence supports regular exercise at near maximum pain tolerance for a minimum of 6 months to increase his maximum walking and pain-free walking distance. The possibility of surgery or endovas-cular luminal revascularization should be borne in mind. As the pain is intermittent and of short duration, at this stage there is no indication for regular analgesia.

After a few months Arthur presents in your clinic again. His pain is now severe and he can hardly walk 50 yards without getting pain in his calf. He also tells you that he wakes up in the middle of the night with pain in his toes, which resolves if he places his foot on the floor.

What treatment will you offer him now?

As his symptoms have worsened it is likely that he will need surgery and will, therefore, need referral to a vascular surgeon or interventional radiologist. In the interim, to control any pain which is not relieved by dropping his foot to the floor, he is likely to require regular analgesia. His analgesic regimen should follow the WHO analgesic ladder of simple analgesics followed by a weak opioid and then a strong opioid, as required. Bearing in mind his comorbidities, NSAIDs may be contraindicated if his renal function is impaired, and opioid doses may need to be reduced accordingly.

Are there any other alternatives?

Lumbar sympathectomy has been advocated in the past, but probably has limited application in this setting. It can still be suggested for older patients with multiple comorbidities in whom surgery may not be recommended.

Unfortunately, despite revascularization surgery, Arthur develops severe complications and the graft fails, leading to acute ischemia. He is brought to hospital with a pale, pulseless, painful cold foot and calf several months after surgery.

What can you offer him now?

This man has acute ischemia and will need a vascular surgical consultation. Treatment options might include embolectomy, repeat revascularization, or amputation depending on the severity and duration of ischemia. Anticoagulation with heparin should be started and analgesia, including the use of strong opioids should be considered. Peripheral nerve block with or without a catheter is also an option and may help with perfusion by causing sympathetic blockade. However, this treatment remains controversial.

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