A 73-year-old male presents to the emergency department with 5 hours of acute right lower extremity pain. Mr. P tells you that the pain came “out of nowhere” while he was reading the morning newspaper. His past medical history is notable for atrial fibrillation, coronary artery disease, and diabetes. He takes warfarin, a baby aspirin, and a statin, and he has an 80-pack-year smoking history.
1. What other parts of the history are relevant?
2. What is the blood supply to the lower extremities?
Acute Limb Ischemia
You first need to understand the pain: the quality, timing, location, onset, and severity. Has he had the pain before? Does he have associated numbness, tingling, or swelling? Does he have pain at rest? Has he ever had pain in the back of his calves, thighs, or buttocks associated with walking? Did it come on suddenly, or has it been worsening over the past few days? Is there any recent trauma to the area?
In terms of past medical history, a history of cardiac or vascular disease is key information: atrial fibrillation, angina/MI, claudication/ulceration, and transient ischemic attacks/strokes. Also notable is a history of cardiac or peripheral revascularization. Current medications are important, as is a personal or family history of cardiac disease, vascular disease, or a hypercoagulable state. Much of the past history gives you an idea as to the cause of ischemia, potential intraoperative challenges, and the perioperative risk associated with intervention.
This is also an appropriate time to gather a quick vascular-oriented review of symptoms. Questions should cover the carotids (visual changes, word-finding difficulties, transient ischemic attacks, or strokes with paralysis or paresthesias), aorta (abdominal or back pain, family or personal history of abdominal aortic aneurysm [AAA]), and peripheral vasculature (claudication, rest pain, ulceration). This is by no means comprehensive, but remember that vascular disease involves numerous territories simultaneously.
On further questioning, Mr. P reveals that the pain behind his right calf started abruptly 5 hours ago. He has been able to walk around, but he notes that the leg is feeling weaker. His activity is so limited at baseline that he normally walks only a few blocks before becoming quite dyspneic. He notes no claudication otherwise, and his vascular review of symptoms is otherwise negative.
He has an 80-pack-year history of smoking, and he also has a history of atrial fibrillation. His warfarin dosing is managed by his PCP, but he takes it regularly with his last INR “above 2.”
The lower extremity circulation begins with the common iliac artery. After the internal iliac branches, the external iliac comes forward and laterally within the pelvis and eventually crosses under the inguinal ligament. After the inferior epigastric and circumflex iliac arteries branch, it is called the common femoral artery (immediately proximal to the inguinal ligament). The next important branch point is ...