This post is an answer to the Case – Arterial Ulcer due to Arteriosclerotic Disease
What is your clinical diagnosis?
An arterial ulcer due to arteriosclerotic disease with occlusion of the left superficial femoral artery.
Why the calf pain on walking?
This is classical calf claudication pain due to muscle ischaemia.
How can a Doppler ultrasonic probe be used to help confirm the diagnosis?
It is used in conjunction with a sphygmomanometer to compare the arm systolic blood pressure with that obtained in the leg. (A special long cuff must be used to take the blood pressure in the lower limb.) There will be a considerable lowering of the ankle blood pressure compared with the brachial pressure (the ankle–brachial pressure index, ABPI).
Indeed, ‘critical ischaemia’ is defined as an ankle systolic pressure that is lower than 50% of the brachial pressure (ABPI < 0.5), although the presence of tissue loss (the ulcer) also signifies that the ischaemia is ‘critical’. Sure enough, this was so in the present case.
What other investigation is required?
She requires further investigation by means of a femoral arteriogram to delineate the arterial tree in the left leg. We need to know if there is a stenosis or total occlusion and whether or not there is an adequate run-off (Fig. 29.2). This will allow reconstruction of the vascular tree, either by a balloon angioplasty, with or without a stent, or surgical reconstruction, using a saphenous vein graft. If there is a totally inadequate run-off, she may well come to amputation of the left leg.