Internal Medicine

P1: SBT

0521779407-04a CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:48

Atherosclerotic Occlusive Disease 183

■Musculoskeletal causes of limb pain (require longer rest to resolve,

rarely originate in calf )

■Diabetic neuropathy (shooting pain or cramps that radiate up and

down the leg, occur at night, rarely localized just to foot)

■Venous ulcers (located at malleolus, painless, other stigmata and

history of venous disease)

management

What to Do First

■Determine if urgent revascularization is needed:

■Symptomatic carotid stenosis –

➣recent TIA

➣resolving stroke with high grade lesion

■Acute mesenteric infarction –

➣severe abdominal pain (out of proportion to tenderness) peri-

toneal signs

acidosis

leukocytosis

■Renal artery

➣Severe bilateral disease with volume overload/pulmonary edema

■Critical limb ischemia – as defined above as Limb Threat

General Measures

■Smoking cessation

■Risk factor control: aggressive management of hyperlipidemia,

hypertension

■Evaluation for hypercoagulable state – most require lifelong antico-

agulation

specific therapy

Carotid Stenosis

■Symptomatic Patients

➣Carotid endarterectomy: all patients with stenosis > 70%, and

any good-risk patient with stenosis > 50%

➣Perioperative combined stroke+death rate must be less than

7% to achieve benefit

■Asymptomatic Patients

➣Perioperative combined stroke+death rate must be less than

5% to achieve benefit

➣Carotid endarterectomy: for any patient with > 80% stenosis and

expected survival greater than 2 years