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Case 2: Painful thigh

A 52 year old man has been smoking heavily most of his life. He now complains of pain in the left posterior calf and thigh after walking 50 metres.

1. What does the angiogram show?

There is complete occlusion of the left external iliac artery with extensive collateral development and reconstitution of the femoral artery in the groin.

2. What further information would you like to know?

On history it is important to assess the risk factors for cardiovascular disease (smoking, hypertension, diabetes, dyslipidaemia, family history) and the presence or abscence of other manifestations of this disease (ischaemic heart disease and cerebrovascular disease) and any previous therapy for these problems.
Next an assessment needs to be made of the severity of claudication and its progress. The duration and progression of symptoms and their impact on lifestyle and employment are critical. A history of complications such as ulceration, gangrene and rest pain increases the risk or limb loss without intervention.
A thorough examination of the entire cardiovascular system is undertaken. Then the angiogram is reviewed to assess disease more proximal and distal as well as in the contralateral limb.

3. How would you manage this man conservatively?

Conservative management is based on risk factor modification (especially cessation of smoking), supervised exercise regime and primary prevention of cardiovascular complications with aspirin antiplatelet therapy. This should involve the general practitioner to assist in ensuring compliance.

Suggested reading: Drug Therapy: Medical Treatment of Peripheral Arterial Disease and Claudication, N Engl J Med 2001; 344:1608-1621, May 24, 2001