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CTA
Differentiating True Claudication from Pseudoclaudication
Intermittent Claudication
Venous Claudication
Pseudoclaudication (Neurogenic)
Character of discomfort Cramping, tightness, tiredness Heaviness and aching Distance to discomfort Exacerbation
Same each time Walking, leg elevation
Relief
Stop walking
tially misleading and may inadvertently lead to downplaying the disease impact on long-term outcomes. Recent data suggest that declining functional performance over time, rather than lack of disease progression, may be the principal dynamic leading to thiS misconception. From a symptomatology stand point; PAD has major detrimental effect on quality of life (slower walking velocity, poorer standing balance score, deceased community ambulation, as well as a taxing economic burden). This is particularly important when considering the demographics of an aging society (> 90% of the elderly in the US, defined as >70 y/o, live independently and almost one fifth of them live alone). These effects of PAD on their mobility would lead them to lose their independence. Differential diagnosis of leg dysfunction (Arteries, Veins, and Nerves) The differential diagnosis of leg dysfunction is broad but could be generally divided into three categories: arterial insufficiency, venous insufficiency, and neuropathic or musculoskeletal in origin. Classically, IC has been differentiated from neurogenic claudication (commonly referred to as pseudoclaudication) [table 1]. Some of the symptomatology seen in chronic venous insufficiency (CVI), such as achy legs and inability to ambulate, may overlap with that seen in PAD. CVI affects 6-7 million individuals in the USA, and similar to PAD, its prevalence increases with age. While some patients may have both PAD and CVI, patients with severe PAD who suffer rest pain tend to develop a moderate degree of pitting edema as a result of keeping their legs in a dependent position in order to alleviate the pain. This, along with the dependent rubor seen in some of these patients, may further confuse the clinical picture. Clues to venous disease include, dilated superficial veins that initially are seen distally and at the medial aspect of the calf, development of pronounced supramalleolar edema at the early stages that later extends to the midcalf with upright posture and resolves with recumbent position, hyperpigmentation secondary to hemosiderin deposition, and lipodermosclerosis with inflammatOIy (stasis) dermatitis. In patients with CVI without PAD, their peripheral pulses are easily palpable. The most common type of leg pain in CVI manifests as heavy achy legs. These may worsen
P24
Same or tingling, weakness, clwnsiness Variable Variable Standing, walking, leg in Variable but usually dependent position standing with or without walking Leg elevation/compression Often must sit or change garment body positions
with conclitions that lead to increased salt and water retention, such as seen during wann humid weather or during menses for women. Leg pain is typically relieved by leg elevation (as opposed to PAD pain which worsens with leg elevation and improves with dangling the leg) Diagnosing PAD-The Value of ABI Measurement of the ankle-brachial index (ABI) offers a qUick, accurate, office-based, and cost effective noninvasive diagnostic test of PAD. Important aspects of this marker include: ABI value between 0.9-1.4 is deemed normal. Values < 0.90 are diagnostic of PAD and values of < 0.4 usually correlate with severe disease, rest pain, and tissue loss. High ABI (> 1.4) is at least as common as low ABI and recent data suggest its clinical significance similar to that of a low ABI « 0.9) (a U-shaper curve for ABI). ABI measures the systemic atherosclerotic burden, predicts all cause as well as cardiovascular mortality (inversely related to survival), and measures PAD severity. ABI is more closely associated with leg function in patients with PAD than is IC or other leg symptoms. ABI has limited use in patients with non-compressible vessels (usually noted in diabetics, patients with chronic renal failure, and the elderly). In these populations, the ABI may be > 1.4 and it usually loses its value as a post-procedure surveillance test. Severely obese patients may also have noncompressible vessels. Selected References are prOvided at the end of syllabus for 1.35 PM talk. 12:35 p.m.
Current Role of Duplex in the Era of MRA!CfA Kenneth S. Rholl, MD Inova Alexandria Hospital Alexandria, VA 12:50 p.m.
MRA: Should Every Patient Have One? Bany Stein, MD Hartford Hospital and Center for Minimally Invasive Thempy, Jefferson X-Ray Group Hartford, CT
Intermittent Claudication
Venous Claudication
Pseudoclaudication (Neurogenic)
Character of discomfort Cramping, tightness, tiredness Heaviness and aching Distance to discomfort Exacerbation
Same each time Walking, leg elevation
Relief
Stop walking
tially misleading and may inadvertently lead to downplaying the disease impact on long-term outcomes. Recent data suggest that declining functional performance over time, rather than lack of disease progression, may be the principal dynamic leading to thiS misconception. From a symptomatology stand point; PAD has major detrimental effect on quality of life (slower walking velocity, poorer standing balance score, deceased community ambulation, as well as a taxing economic burden). This is particularly important when considering the demographics of an aging society (> 90% of the elderly in the US, defined as >70 y/o, live independently and almost one fifth of them live alone). These effects of PAD on their mobility would lead them to lose their independence. Differential diagnosis of leg dysfunction (Arteries, Veins, and Nerves) The differential diagnosis of leg dysfunction is broad but could be generally divided into three categories: arterial insufficiency, venous insufficiency, and neuropathic or musculoskeletal in origin. Classically, IC has been differentiated from neurogenic claudication (commonly referred to as pseudoclaudication) [table 1]. Some of the symptomatology seen in chronic venous insufficiency (CVI), such as achy legs and inability to ambulate, may overlap with that seen in PAD. CVI affects 6-7 million individuals in the USA, and similar to PAD, its prevalence increases with age. While some patients may have both PAD and CVI, patients with severe PAD who suffer rest pain tend to develop a moderate degree of pitting edema as a result of keeping their legs in a dependent position in order to alleviate the pain. This, along with the dependent rubor seen in some of these patients, may further confuse the clinical picture. Clues to venous disease include, dilated superficial veins that initially are seen distally and at the medial aspect of the calf, development of pronounced supramalleolar edema at the early stages that later extends to the midcalf with upright posture and resolves with recumbent position, hyperpigmentation secondary to hemosiderin deposition, and lipodermosclerosis with inflammatOIy (stasis) dermatitis. In patients with CVI without PAD, their peripheral pulses are easily palpable. The most common type of leg pain in CVI manifests as heavy achy legs. These may worsen
P24
Same or tingling, weakness, clwnsiness Variable Variable Standing, walking, leg in Variable but usually dependent position standing with or without walking Leg elevation/compression Often must sit or change garment body positions
with conclitions that lead to increased salt and water retention, such as seen during wann humid weather or during menses for women. Leg pain is typically relieved by leg elevation (as opposed to PAD pain which worsens with leg elevation and improves with dangling the leg) Diagnosing PAD-The Value of ABI Measurement of the ankle-brachial index (ABI) offers a qUick, accurate, office-based, and cost effective noninvasive diagnostic test of PAD. Important aspects of this marker include: ABI value between 0.9-1.4 is deemed normal. Values < 0.90 are diagnostic of PAD and values of < 0.4 usually correlate with severe disease, rest pain, and tissue loss. High ABI (> 1.4) is at least as common as low ABI and recent data suggest its clinical significance similar to that of a low ABI « 0.9) (a U-shaper curve for ABI). ABI measures the systemic atherosclerotic burden, predicts all cause as well as cardiovascular mortality (inversely related to survival), and measures PAD severity. ABI is more closely associated with leg function in patients with PAD than is IC or other leg symptoms. ABI has limited use in patients with non-compressible vessels (usually noted in diabetics, patients with chronic renal failure, and the elderly). In these populations, the ABI may be > 1.4 and it usually loses its value as a post-procedure surveillance test. Severely obese patients may also have noncompressible vessels. Selected References are prOvided at the end of syllabus for 1.35 PM talk. 12:35 p.m.
Current Role of Duplex in the Era of MRA!CfA Kenneth S. Rholl, MD Inova Alexandria Hospital Alexandria, VA 12:50 p.m.
MRA: Should Every Patient Have One? Bany Stein, MD Hartford Hospital and Center for Minimally Invasive Thempy, Jefferson X-Ray Group Hartford, CT