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1.
Am Fam Physician ; 59(7): 1899-908, 1999 Apr 01.
Article in English | MEDLINE | ID: mdl-10208708

ABSTRACT

Chronic critical limb ischemia is manifested by pain at rest, nonhealing wounds and gangrene. Ischemic rest pain is typically described as a burning pain in the arch or distal foot that occurs while the patient is recumbent but is relieved when the patient returns to a position in which the feet are dependent. Objective hemodynamic parameters that support the diagnosis of critical limb ischemia include an ankle-brachial index of 0.4 or less, an ankle systolic pressure of 50 mm Hg or less, or a toe systolic pressure of 30 mm Hg or less. Intervention may include conservative therapy, revascularization or amputation. Progressive gangrene, rapidly enlarging wounds or continuous ischemic rest pain can signify a threat to the limb and suggest the need for revascularization in patients without prohibitive operative risks. Bypass grafts are usually required because of the multilevel and distal nature of the arterial narrowing in critical limb ischemia. Patients with diabetes are more likely than other patients to have distal disease that is less amenable to bypass grafting. Compared with amputation, revascularization is more cost-effective and is associated with better perioperative morbidity and mortality. Limb preservation should be the goal in most patients with critical limb ischemia.


Subject(s)
Ischemia/diagnosis , Ischemia/therapy , Leg/blood supply , Amputation, Surgical , Chronic Disease , Critical Illness , Diagnosis, Differential , Humans , Ischemia/etiology , Ischemia/physiopathology , Pulse , Risk Factors , Wound Healing
2.
Am Fam Physician ; 56(4): 1081-90, 1997 Sep 15.
Article in English | MEDLINE | ID: mdl-9310060

ABSTRACT

Abdominal aortic aneurysms occur in 5 to 7 percent of people over age 60 in the United States. An aneurysm is defined as a permanent localized dilatation of an artery, with an increase in diameter of greater than 1.5 times its normal diameter. Abdominal aortic aneurysms may be manifested by catastrophic rupture, signs of pressure on other viscera or an embolism originating in the aneurysmal wall, but most cases are asymptomatic. The diagnosis is often made by physical examination of the abdomen, which reveals a pulsatile mass left of the midline, between the xyphoid process and the umbilicus. The diagnosis may be confirmed by B-mode ultrasound. Ultrasound screening should be considered for individuals at risk for abdominal aortic aneurysms. This group includes individuals over age 60 who smoke, have hypertension or have vascular disease. Elective surgical intervention is indicated for most patients with abdominal aortic aneurysms greater than 5 cm in diameter to prevent rupture and death. Smaller abdominal aortic aneurysms should be monitored by regular ultrasound measurements. Screening and identification of abdominal aortic aneurysms by primary care physicians can have a significant impact on patient survival.


Subject(s)
Aortic Aneurysm, Abdominal/diagnosis , Aortic Aneurysm, Abdominal/surgery , Aortic Aneurysm, Abdominal/etiology , Diagnosis, Differential , Humans
3.
Am Fam Physician ; 53(4): 1245-53, 1996 Mar.
Article in English | MEDLINE | ID: mdl-8629569

ABSTRACT

Claudication is exercise-induced lower extremity pain that is caused by ischemia and relieved by rest. This underreported condition affects at least 10 percent of persons over 70 years of age and 2 percent of those 37 to 69 years of age. Claudication is usually caused by atherosclerotic narrowing of the arteries that supply blood to the lower extremities. The diagnosis may be suspected based on the history and the physical examination, and it is confirmed by Doppler segmental pressures and an ankle/brachial index. Initial treatment includes vigorous risk factor modification and an exercise program. Further treatment includes pentoxifylline and, occasionally, endovascular or bypass procedures.


Subject(s)
Intermittent Claudication/diagnosis , Intermittent Claudication/therapy , Algorithms , Angiography , Arterial Occlusive Diseases/diagnosis , Arterial Occlusive Diseases/physiopathology , Combined Modality Therapy , Exercise , Humans , Intermittent Claudication/physiopathology , Risk Factors , Ultrasonography, Doppler , Vascular Surgical Procedures/methods
4.
Am Fam Physician ; 53(2): 549-56, 559-60, 1996 Feb 01.
Article in English | MEDLINE | ID: mdl-8629537

ABSTRACT

Prevention of stroke caused by carotid bifurcation stenosis can be achieved by accurate identification and evaluation of patients at risk. A consensus report from the National Institute of Neurologic Disorders and Stroke has standardized diagnostic criteria and symptoms related to this disease. Recent prospective, randomized trials have identified effective treatment for both asymptomatic and symptomatic carotid stenosis. The risk factors for carotid stenosis are similar to those for atherosclerosis--hypertension, diabetes, cigarette smoking and hyperlipidemia. A carotid bruit is the most common clinical finding, although its positive predictive value is only about 60 to 70 percent. Recent clinical trials have identified patient groups that benefit from surgical and medical therapy, depending on the degree of carotid stenosis and the presence or absence of symptoms. Symptomatic patients with carotid stenosis greater than 70 percent benefit from surgical therapy. Asymptomatic patients who have carotid stenosis greater than 60 percent and are good surgical candidates should be referred for surgical consultation.


Subject(s)
Carotid Stenosis/complications , Cerebrovascular Disorders/prevention & control , Algorithms , Carotid Stenosis/therapy , Cerebrovascular Disorders/etiology , Humans
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