Vascular

CASE 49: a numb anD painFul hanD

history

A 43-year-old woman presents to the vascular clinic with cramping pain and numbness in the left hand. This morning she has noticed a black patch on the tip of her thumb and index finger. She is a heavy smoker and is on medication for hypertension.

examination

On examination, the hand is warm and well perfused, with a palpable radial pulse. Allen’s test is normal and there is no upper limp neurological deficit. A hard bony swelling is palpable in the supraclavicular fossa. It is not pulsatile and is immobile. A plain radiograph of the thoracic inlet is shown in Figure 49.1.

Figure 49.1 plain anterior-posterior x-ray of the lower cervical spine.

Questions

•What abnormality can be seen in the x-ray?

•What is its incidence in the general population?

•How can the symptoms and signs be explained?

•What is the differential diagnosis?

•What further investigations may be helpful?

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100 Cases in Surgery

ANSWER 49

Figure 49.2 plain x-ray demonstrating a cervical rib (arrow).

The x-ray shows a cervical rib (arrow in Figure 49.2).

Cervical ribs have an incidence of around 0.4 per cent in the general population. The subclavian artery runs over the rib and can be compressed against it. An aneurysm of the artery developing at the point of compression is a rare complication. Thrombus within the aneurysm sac can embolize to the digital arteries and can cause fingertip gangrene or even digital infarction. Thrombosis and occlusion of the subclavian artery can also occur. The brachial plexus runs with the cervical rib, and compression of the T1 nerve root can cause numbness, paraesthesia and weakness. Symptoms maybe relieved by surgical excision of the rib.

The thoracic outlet syndrome can be mimicked by:

•Prominent cervical discs

•Spinal cord tumours

•Cervical spondylosis

•Pancoast tumours

•Osteoarthritis of the shoulder

•Carpal tunnel syndrome

•Ulnar neuritis

An electrocardiogram is required to exclude embolisation secondary to cardiac arrhythmias such as atrial fibrillation. A colour Doppler ultrasound scan or an angiogram would determine the presence of a subclavian aneurysm and allow assessment of the distal circulation.

KEY POINTS

•Cervical ribs have an incidence of around 0.4 per cent in the general population.

•Symptoms may be relieved by surgical excision of the cervical rib.

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Vascular

CASE 50: pain in the CalF on WalKing

history

A 69-year-old man attends the vascular clinic complaining of a cramping pain in the right calf on walking 150 yards. The pain is worse on an incline and is quickly relieved by rest. The pain is then reproduced after walking the same distance. There is no history of trauma or previous surgery.

examination

There are no skin changes in the right leg. The right femoral pulse is present but the right popliteal, dorsalis pedis and posterior tibial pulses are absent. A bruit is audible over the right adductor canal. There is no abdominal aortic aneurysm and the rest of the examination is unremarkable.

An angiogram is done and is shown in Figure 50.1.

SPA

PFA

Figure 50.1 angiogram of the right lower limb. pFa, profunda femoris artery; SFa, superficial femoral artery.

Questions

•What is the most likely diagnosis?

•What are the differential diagnoses for this condition?

•What are the other important points to ascertain from the history?

•What other investigations are required?

•What treatment would you advocate for this man?

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100 Cases in Surgery

ANSWER 50

The most likely diagnosis is intermittent claudication. The angiogram demonstrates a stenosis in the superficial femoral artery at the adductor canal (arrow in Figure 50.2).

SPA

PFA

Figure 50.2 angiogram revealing stenosis in the femoral artery at the adductor canal (arrow).

!Differential diagnoses

The patient should be questioned about risk factors for atherosclerotic disease including cigarette smoking, diabetes, family history, history of cardiac disease, hyperlipidaemia, hyperhomocysteinaemia and hypertension.

Investigations should include ankle–brachial pressure index (ABPI): this is typically <0.9 in patients with claudication; however, calcified vessels (typically in patients with diabetes) may result in an erroneously normal or high ABPI. Other tests include measurement of blood sugar and lipids. A duplex ultrasound will determine if there are any significant stenoses or occlusions in the lower limb arteries.

The disease will only progress in one in four patients with intermittent claudication: therefore, unless the disease is very disabling for the patient, treatment is conservative. This should include reducing the risk of cardiovascular events through secondary prevention:

•Smoking cessation

•Statins

•Antiplatelet drugs

•Blood pressure control

•Tight diabetes control

Regular exercise has been shown to increase the claudication distance. In the minority of cases that do require intervention (i.e. severe short distance claudication not improving with exercise), angioplasty and bypass surgery are considered. Angioplasty has a better outcome in single-level, short stenoses/occlusions, particularly in the iliac arteries.

KEY POINTS

•risk factors should be addressed as part of the initial management.

•patients should be encouraged to exercise to improve the collateral circulation.

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