Marcus Brooks and Fabien Koskas

A 63-year-old man presents with a history of worsening pain in his left buttock, thigh and calf on walking. During the preceding 3 months, following the introduction of a beta-blocker for newly diagnosed hypertension, the distance he could walk at a “normal” pace had reduced from 200 to 100 m. The pain ceased almost immediately after stopping walking and appeared again after the same interval. A systemic enquiry revealed recently diagnosed hypertension and life-long history of heavy smoking. He had never experienced cerebro-vascular or cardiac symptoms.

Clinical examination revealed sinus rhythm, full upper limb pulses, a diminished left femoral pulse and absent left popliteal and pedal pulses. The right leg pulses were normal. Both feet appeared well perfused. No bruits were audible in the abdomen or groins. The abdominal aorta was not aneurismal. Ankle pressure brachial indices were 0.74 on the left and 0.93 on the right at rest. On treadmill walking for 100 m the left ankle pressure fell to 0.49.

Question 1

Which of the following would be part of your initial management of this patient?

A.  A prescription for nicotine replacement therapy. B.  A prescription for warfarin.

C.  A prescription for aspirin. D.  A prescription for a statin. E.  Stopping the beta-blocker.

Theclinicalfindingsweresufficienttomakethediagnosisofperipheralarterialdisease(PAD). The patient was advised as to the risk of smoking and referred to the local smoking cessation clinic. Best medical therapy was instituted for PAD. It was decided not to investigate further at this stage but to review in three months. After three months the patient had successfully managed to stop smoking and was taking the medication prescribed. His left leg claudication,

M. Brooks ( )

Department of Vascular Surgery,

University Hospitals Bristol NHS Foundation Trust, Bristol, UK

however, had not deteriorated. He was also now complaining of erectile dysfunction. As the patient was shortly to be retiring and was an enthusiastic hunter he was very keen for any intervention that might improve his walking distance and impotence.

Question 2

How would you proceed with your management at this second clinic visit?

A.  No further intervention.

B.  A prescription for Cilostazol (PletalTM, Otsuka Pharmaceuticals Co.) C.  Obtain arterial imaging to define the pattern of arterial disease.

D.  Enrolment of the patient in a supervised exercise programme.

Question 3

Which of the following is not an appropriate first line imaging modality?

A.  Duplex ultrasound.

B.  Contrast-enhanced CT scan (CTA).

C.  Contrast-enhanced magnetic resonance angiography (MRA). D.  Intra-arterial digital subtraction contrast angiogram (IADSA).

The patient underwent an arterial duplex scan. This scan showed a significant stenosis at the left internal iliac artery origin and a short but tight stenosis of the proximal left external iliac artery.Thecontra-lateraliliacsystemwasfoundtobefreefromsignificantdisease,aswerethe femoralandpoplitealarteriesinbothlegs.Thecruralarterieswerenotformallyassessedusing duplex. This pattern of disease was confirmed on subsequent angiographic images (Fig. 17.1).

Question 4

Into which of the following TransAtlantic Inter-Society Consensus (TASC) categories would you put both the internal and external iliac artery lesions?

A.  TASC A

B.  TASC B

C.  TASC C

D.  TASC D

E.  TASC E

Question 5

Which of the following would you consider as possible interventions?

A.  Aorto-bifemoral bypass graft. B.  Left aorto-uni-iliac bypass graft.

C.  Right femoral to left femoral cross-over graft.

c

Fig. 17.1  Images from the digital subtraction angiogram showing (a) the renal arteries, infrarenal aorta and iliac bifurcation, (b) internal iliac and proximal external iliac stenoses, and (c) an oblique projection of the left iliac system

D.  Percutaneous transluminal angioplasty via a right common femoral puncture. E.  Percutaneous transluminal angioplasty via a left common femoral puncture.

A percutaneous transluminal angioplasty was performed from the left groin under local anaesthesia.Firsta4Fsheathandpigtailcatheterwereusedtoobtainadiagnosticangiogram, as seen in Fig 17.2. The angiogram was performed to visualize the left iliac disease, but also

Fig. 17.2  Angiogram performed for investigation of the patient’s erectile dysfunction and worsening of left thigh and calf intermittent claudication

the crural arteries which had not been imaged with duplex. The diagnostic angiogram confirmed the duplex findings and revealed normal runoff arteries below the knee. The sheath was therefore changed to 6F and systemic heparin given. A SOS OMNI® catheter was used to direct a guide wire across the bifurcation. The guide wire was then steered first into the internal iliac and then the external iliac arteries with balloon angioplasties performed.

Question 6

What size of balloon is likely to be needed to dilate the internal and external iliac arteries in this man?

A.  2 mm B.  4 mm C.  7 mm

D.  10 mm E.  12 mm

A completion diagnostic angiogram confirmed a good result. The right femoral sheath was removed with manual pressure over the puncture site. The left leg pulses were restored by the procedure.

Question 7

Which of the following statements describe the optimal follow-up for this patient?

A.  Low-dose subcutaneous low-molecular-weight heparin (LMWH) for 3 months. B.  Enrolment of the patient in a supervised exercise programme.