Parks 915-BL Operating & Service Manual page 35

OFFICE TECHNICS FOR VASCULAR TESTING -
resistance provided by the attendant's hand. Alternatively,
the patient can be instructed to rapidly perform toe lifts
until fatigue or calf pain develops. These methods are
less standardized than treadmill exercise, but they have
the advantage of requiring no special equipment.
If the initial ankle systolic pressure after exercise is equal
to or higher than pre-exercise values, then the test is
normal and no further measurements are required. If the
initial ankle pressure is low, the measurements are repeated
every minute for the next ten minutes. It should be
emphasized that the Doppler survey, ankle pre ssure
measurements, and exercise testing can be done in less
than 20 minutes by paramedical office personnel.
The following cases are presented to illustrate the
usefulness of vascular testing methods in the clinical
situation.
Case Reports
C a s e 1 . A 5 2 - y e a r- o l d m a n c a m e t o t h e m e d i cal
clinic complaining of pain involving the right leg, thigh,
and buttock. The pain was precipitated by walking one
block and relieved by rest. Physical examination of
the right leg showed 2+ femoral and dorsalis pedis pulses
and a weakly palpable posterior tibial pulse. No trophic
changes or temperature differences between the two legs
were observed. It was the physician's initial impression
that the slightly diminished pulses probably were not
responsible for the symptoms, but the patient was
referred to the vascular surgery c l i n i c f o r f u r t h e r
s t u d i e s a t t h a t t i m e . T h e s u r v e y with the Doppler
ultrasonic velocity detector revealed abnormal signals
at the right femoral, popliteal, dorsalis pedis, and
posterior tibial areas. The brachial systolic pressure was
112 turn Hg. The right ankle systolic pressure was 86
mm. Hg. The patient was able to walk 115 yards at 3
mph on the treadmill.
These studies suggested the presence of severe occlusive
atherosclerosis of the right iliac artery. Angiography
confirmed a high-grade stenosis of the e nt i re ri gh t
common iliac artery and its bifurcation. An aortoiliac
endarterectomy was done subsequently. Postoperatively
the patient was completely asymptomatic. Survey with
the ultrasonic velocity detector showed normal flow in
both lower extremities. The brachial systolic pressure
was 140 mm Hg. The ankle systolic pressures were 137
turn Hg on the right and 140 mm Hg on the left.
Comment. At the time the patient was initially seen in
the general medicine clinic, his complaints were
suggestive of severe occlusive arterial disease. The fact
that pulses were palpable in all areas, however, was
confusing to the physicians who first saw him. When he
was examined in the vascular laboratory using the
Doppler ultrasonic velocity detector the lesion was
quickly localized to the right iliac artery. The 34
turn Hg arm/ankle gradient demonstrated the severity
of the problem, and the functional disability was
confirmed by his performance on the treadmill. Since the
patient's job required a great deal of walking he was
essentially disabled by his condition. On the basis of
the objective tests, proper, diagnosis and treatment
were begun.
20
Hagood et al
Doppler survey and ankle pressure measurements not
only suggested the correct diagnosis preoperatively,
but also confirmed the salutory effect of the surgical
procedure post-operatively. Patients with symptoms
suggestive of claudication and intact pulses may be
mistakenly treated for arthritis, neuritis, or emotional
p r o b l e m s . A s w a s s h o w n i n t h i s c a s e , t h e c o r r e c t
diagnosis can be quickly and accurately made, using
simple testing procedures.
Case 2. A 62-year-old man with many complicated
medical problems came to our clinic with complaints
of pain in the right calf and night pain. Pain in the
calf was precipitated by walking less than 100 ft and
relieved by rest. Physical examination of the right
leg showed a normal pulse in the groin. No other
pulses were palpable. The right brachial systolic blood
pressure was 206 mm. Hg. The right ankle systolic
pressure was 78 turn Hg. Survey with the Doppler
ultrasonic velocity detector showed a slightly abnormal
flow signal high in the right groin. This signal became
high-pitched and continuous at a point about two inches
b e l o w t h e i n g u i n a l l i g a m e n t , a n d l o w - p i t c h e d ,
monotonous signals were noticed distal to that level.
He walked for 108 yards on the flat treadmill at 3
mph. There was a 66.5% decrease in ankle systolic
pressure after exercise. An arteriogram done by the
Seldinger technic showed minimal decrease in the aorta
and the right iliac artery. The superficial femoral artery
was occluded in Hunter's canal. Close inspection of the
bifurcation of the common femoral artery suggested
significant occlusive disease, involving the origin of the
deep femoral artery.
Due to the patient's poor state of general health, the
right groin was explored under local anesthesia. A large
occlusive plaque was located in the common femoral
artery and a tight stenosis of the deep femoral orifice
was observed. A common femoral and deep femoral
endarterectomy were done. The patient was examined
i n t h e l a b o r a t o r y t h r e e m o n t h s a f t e r o p e r a t i o n .
Brachial systolic pressure was 132 mm. Hg. The right
ankle systolic pressure was 70 mm. Hg. He walked 1,000
y a r d s o n t h e f l a t t r e a d m i l l a t 3 m p h w i t h a 61%
decrease in ankle pressure after exercise.
Comment. The history and physical findings were not
compatible with an isolated, superficial femoral artery
obstruction. Disabling claudication and night pain are
usually indicative of multiple arterial occlusions. The
128 mm Hg pressure gradient between the arm and
ankle suggested that this was the case. Since a full
femoral pulse was palpated, and only a slightly abnormal
Doppler flow signal was heard in the upper common
femoral artery, it was thought that the o b s t r u c t e d
arteries were located in the thigh or calf or both.
The presence of arterial signals in the popliteal artery
indicated its patency. Doppler examination of the
dorsalis pedis and posterior tibial arteries showed arterial
flow signals similar to those obtained in the popliteal
artery. This suggested no significant obstructive lesion
between these levels. On the basis of these findings,
t h e o b s t r u c t i v e l e s i o n s could be localized to the
superficial and deep femoral arteries.
SOUTHERN MEDICAL JOURNAL,Vol 68, No. 1