A case of peripheral vascular disease, vascular surgons/ intervention cardiologist please?

Question

One of my patient named Mr. Dhirajbhai Shah 69yrs/ male, he is known case of

Diabetes > 10 yrs

Hypertension > 10 yrs

Ventricular outflow obstruction in brain > 10 yrs

Diabetic nephropathy for last 3 yrs

Benign prostatic hypertrophy for last 6 months

Operated case of CABG and Cholecystectomy,

He developed pain in both legs, pain increases at the time of walking, one limb is swalloen because of filariasis from a long time, his sugar level is under control, s. creatinine is 2.3, no other gross abnormalities in blood reports.

His MR angio of both lowerlimb reveals,

* Narrowing of the distal portion of abdominal aorta

* Non visualisation of right common iliac artery with reformation of right external iliac via collaterals

* Block of proximal and middle thirds of superficial femoral arteries, bilaterally with reconsitution of lower thirds.

* Non visualisation of right anterior and posterior arteries

* non visualisation of middle and distal thirds of left tibial arteries.

Medication : at present he on Oral hypoglycemic agents with sos insulin

Losar H ( Losartan with hydrochlorthiazide 50 + 12.5)

Ecosprin 150 mg ( Aspirin)

Clopidogral 75 mg

Acitrom 2 mg

Atorvastatin 20 mg bed time

Trental 400 mg tds

Symptomatic medicine

As patient is not very much co operative and inspite of chances of renal failure requiring dialysis personally relatives would like to go for non invesive procedure.

Thanking you

Yours sincerly

Dr. Nemish gandhi M.D.
Consultant physician.

Krishna clinic
1/1026 choki street,
Nanpura,
Surat. : 395001
Gujarat
India

m :092279 02941
098252 89330

Answer 1

MR angio is famous for not well visualising the lower extremity arteries in detail.

Without seeing the angios, it hard to tell if an endovascular procedure would work. It might be worth it to get a standard angiogram (after proper premedication and hydration). This would provide the interventionalist with badly needed info. If there is significant stenosis in the aorto-iliac vessels, it might be treated with stents.

One possiblity is athrectomy using a device called the Silver Hawk.

However, this isn't always possible/successful.

A bypass would only work if there are good target vessels below the SFAs.

Difficult situation. Best of luck.

Answer 2

1

Answer 3

Of course this is a very complicated case - in a patient who does not want intervention.

You have him on a variety of anti-platelet/anti-coagulation medications - apparently with persistent symptoms.

ASA
Clopedigrel
Warfarin (Acitrom)
Trental

Does this patient have pain at rest or evidence lack of perfusion at rest (dusky, cool limb)? If so, despite the patient's desire not to have intervention, it would then be necessary. Up until that point, intervention can be avoided.

I might consider trying to improve the function of the driving pump - the heart.

1. Depending on the patient's ejection fraction, I might consider Coreg if EF is less than 50%. Start slowly and advance the dosing as tolerated.
2. I also might consider Isosorbide Mononitrate. It will often improve cardiac function a little AND give you some vasodilation in the extremities. A transdermal nitro patch will work here too.
4. I might add digitalis to increase heart contractility. (Very careful dosing with this patient's renal failure)
3. Instead of HCTZ and ARB, I might use Hydralazine (preserve kidney function) and Lasix if a diuretic is needed. Reduce edema as much as possible in the periphery.
4. If not already - ideally control b/p to 110 to 120 systolic.
5. I would be VERY agressive with cholesterol control and use maximum dose of a statin - possible with an adjunct like ezetimbe.

I am not certain these things would help considering your patient's extensive disease, but sometimes small measures make substantial differences.

Thank you for sharing this interesting case. Good luck to you.

Answer 4

I wonder if India has a law similar to the American HIPPA in regards to confidentiality.

By the way what is the question?