Knee / Ankle / Foot

Pain in Critical Ischemic Vascular Disease Lower Extremities

Definition

The definition of pain in critical vascular disease is described as a sign of vascular insufficiency of the distal extremities.

Aetiology

A systemic vascular disease such as arteriosclerosis generally causes vascular insufficiency. It is most frequent seen in patients older than 55 years, with a yearly incidence of 0,25 to 0,45 patients per 1000 inhabitants. Critical ischemic disease is often caused by arteriosclerosis due to hypertension or diabetes.

Signs and Symptoms

In case of critical ischemic disease due to arteriosclerosis, patients often indicate evolution of nonspecific pain in the extremities while walking that disappears at rest. (Intermittent claudicatio).  Eventually, slow-healing ulcers will develop. Critical ischemic disease predominantly occurs in the older population. This is in contrast to Buerger's disease in which the first symptoms are also atypical pain with eventual discoloration and ulceration.

Diagnostics

Physical Examination

General examination is important to exclude "red flags" and to evaluate the patient's health (weight loss, malignancy) is relevant. The blood pressure should be measured and examination focusing on disorders of the connective tissues or on peripheral vascular disease should be carried out. The hands and feet should be inspected for wounds and ulcers and the possible presence of dilated capillaries in the nail bed is also important.

 

Classification of critical vascular disease is done according the Fontaine classification. For interventional pain treatment are Fontaine III and IV important.

Because of insufficient muscular blood supply, patients with Fontaine III have pain in rest and in supine position. Frequently the pain becomes less by hanging down of the extremities. Patients with Fontaine IV have trophic skin disorders such as necrosis and/or gangrene.

Additional Somatic Diagnostics

  • In case of critical ischemic vascular disease, the imaging of the arteries of the extremities will be important

Additional Psycho-cognitive Diagnostics

  • RAND-36 (quality of life)
  • VAS-Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis.  Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment consisting of various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

  • Treatment Fontaine III en IV patients is aimed at prevention of amputation by pain reduction and ulcer care.
  • Initially, the treatment is conservative and medicinal, in order to treat the underlying disease. If complaints persist, referral to a vascular surgeon is indicated.

Interventional Pain Treatment