CASE 215: A 67 YEAR OLD WITH A PAIN IN THE BUTT

History A 67-year-old gentleman is admitted complaining of a dull aching pain in the right buttock and right thigh. The pain is making it impossible for him to walk. Four years ago, the patient had an episode of severe chest pain. Heart catherization at the time showed a lesion on the left anterior descending coronary artery which was dilated with balloon angioplasty. The patient also states that there has been pain in the legs after walking more than one block over the past two years, but generally he has modified his life style to avoid walking.

P. E an anxious individual with severe leg pain; his pulse is 84 and regular, resp. 16, temp. 38°C, HEENT is negative except for arcus senilis and a faint left carotid bruit. Chest examination reveals occasional rhonchi but no rales. The heart exam is essentially normal. Abdominal exam is unremarkable. Lower extremities show loss of hair below the knees bilaterally and the skin is shiny and irregularly pigmented. There are no ulcerations and no skin temperature differences. The right leg is slightly dusky.

Pulses Pulses:RadialFemoralPoplitealPost- tibial Dorsalis pedis Left Right What is the your problem list and admitting diagnosis and differential? What laboratory tests would you order now?

Labs CBC: Hgb:14g/dL Hct:45% RBC:5.0x10 6 /  L WBC:7.0x10 3 /  L Sodium:140 mMol/LPotassium: 3.8 mMol/LHCO 3 -:25 mMol/LChloride:100 mMol/L glucose120 mg/dL BUN 21 mg/dLCalcium: 10.0 mg/dLPhosphorous: 3.0 mg/dLProtein: 7.5 mg/dLAST:39 IU/LCholesterol:260 mg/dLTriglycerides:390 mg/dL HDL: 32 mg/dL Interpret the lipid findings and what would you do about them. Any changes to you differential. What would you order now?

Vascular ultrasound showed severe obstructive atherosclerosis of the iliac and femoral arteries with almost complete occlusion. The vascular surgeon performed a ilio-popliteal bypass. There was initial good perfusion of the leg. The patient was released and counseled as to the necessity to stop smoking, modify his diet, and lose at least 25 pounds. One year later, the patient came in with a numb, cold right leg. Angiography showed occlusion of the distal part of the graft. The vascular surgeon and interventional radiologist attempted to angioplasty the distal portion of the graft and a portion of the distal popliteal artery. After one week of intensive anticoagulant therapy, they found it was impossible to maintain the patency of the graft and distal popliteal artery. Irreversible ischemia developed and the leg had to be amputated.

The specimen

Section of the anterior tibial artery Trichrome elastic stain : Internal elastic membrane Intimal plaque Should be lumen

Another area of the ant. tibial artery Calcification

Muscle atrophy and degeneration

Early Gangrene

What type of necrosis is going on here? What is Leriche ’ s syndrome? How do you distinguish arterial from venous peripheral vascular disease? What role do the following play in peripheral vascular disease: Diabetes and smoking Distinguish atherosclerosis obliterans from thromboangiitis obliterans.

Thromboangiitis obliterans-Buerger ’ s disease

Diabetic vascular disease (small vessel disease)

You have been asked to give a brief overview of the pathogenesis of atherosclerosis to a group of high school science teachers. What would you say? Design a diagram for your presentation.