Name of the patient : Achuthan
Age : 67 yrs
Sex : Male
Address : Karadayil House
Choolor (P.O)
Near REC
Occupation : Stone Cutter.

Date of admission : 10-02-2004
Admission No. : 1055

Presenting Complaint:
1. Ulcer on lateral side of little finger of left leg since 1½ months.
2. Aching pain of both lower limbs since 3 years.
3. Chest pain and difficulty in breathing since 2 years.

History of Presenting Complaint:
The complaint started about 3 years back as aching pain in both lower limbs below knee joint which was aggravated on walking. Now there is pain in both lower limbs from thigh to foot even during rest. Pain is aggravated at night and least motion. Slight relief for pain by hanging down the limbs along the sides of the bed. The pain in the limbs is associated with numbness.
The ulcer on foot developed as a crack and the patient neglected it and it developed into an ulcer. There is severe itching in both limbs and peeling of skin since 1 week. Discharge from ulcer is blackish and offensive and scanty.
The difficulty in breathing started about 2 years back. Using bronchodilators regularly. It is associated with cough.
There is severe chest pain with sweating occasionally even during rest.

Past History:
Hypertensive
Suffering from diabetes mellitus.
H/o tuberculosis and ATT was taken for 7 months.
H/o Coronary artery disease

Personal History:
Born and bought up at Chathamangalam. Studied up to 4th standard. Was a manual laborer – stonecutter. Married and has 6 children. Belongs to low socio-economic class. Was a heavy smoker since childhood.

Family History:
Grand mother died of cancer.
Brother – tuberculosis.

Regionals:
Stomach
Appetite : Reduced
Thirst : good
Desire : nothing peculiar
Aversion : Meat
Rectum
Bowel : regular
Urine : no complaints
Sweat : Increased during pain
Sleep : Decreased due to pain. Prefers uncovering, general > by fanning.

Mind : Even though there is severe pain the patient is very mild, without much complaining.

Treatment History:
Chemical sympathectomy done 4 months back with temporary relief. Was taking morphine for pain before admission. Patient is advised for angioplasty, is not willing due to financial problems.

Examination of the patient:
General Survey:
Patient is ill built and ill nourished.
Conjunctival pallor present.
No cyanosis, not icteric, Clubbing present – 2nd degree.
No pedal oedema, no generalized or localized lymphadenopathy.
Blood pressure : 110/70 mm of Hg.
Radial pulse : 60/mt
Respiratory rate : 16/mt
Temperature : 98.20F

Local Examination :
(i) Examination of the peripheral vascular system:
On inspection there are 2 ulcers round in shape on dorsum of left foot over the 4th and 5th metatarsal bones. The floor is covered by pale granulation tissue. There is scanty purulent discharge. Both lower limbs show signs of ischaemia like thinning of skin, diminished growth of hair, loss of subcutaneous fat, brittle nails with transverse ridges. Patient is unable to perform Buerger’s postural test due to severe pain.
On palpation the ulcer is tender to touch. Its base is on the 4th and 5th metatarsals and it is about 2mm deep and 1cm in diameter. No induration and not bleeding on touch. Both lowerlimbs are cold to touch. Capillary refilling time is prolonged.
Venous refilling is very slow.
Arterial pulsation absent in femoral, popliteal, anterior and posterior tibial and dorsalis pedis arteries on both sides.

Examination of other Systems

Cardiovascular system : No abnormality detected.
Nervous system : No abnormality detected.
Gastro intestinal system : No abnormality detected.
Respiratory system :Rhonchi in all lung fields. Chest expansion is reduced. Breath sound is vesicular with prolonged expiration.

PROVISIONAL DIAGNOSIS :
ISCHAEMIA DUE TO ARTERIAL STENOSIS OF LOWERLIMB.

INVESTIGATIONS:

On 30-12-03 FBS - 84 gm%
PPBS – 126 gm%
14-02-03 RBS – 100 gm%

ECG : ST depression and T wave inversion in V4 and V5 leads.

11-08-03 Echocardiography : Aortic valve thickened, Trivial AR/MR.

11-08-03 Doppler study of arterial system of both lower limbs : Atherosclerotic changes in aorta, both common iliac and external iliac arteries. Extensive atherosclerotic changes with calcification and total occlusion of superficial femoral artery on either side and distal reformation of tibial (ant & post) with monophasic ischaemic flow.

26-11-03 X-ray chest – AP view : Right upper lobe – cavity.

CLINICAL DIAGNOSIS:
Peripheral atherosclerotic disease due to bilateral occlusion of superficial femoral artery on both sides.

ANALYSIS OF SYMPTOMS:
Symptoms of disease     Symptoms of Patient
Pain limbs < night            Mildness of mind
> hanging down the limbs General > covering
Ulcer on foot > fanning
Chest pain with sweating      Aversion meat
H/o tuberculosis

EVALUATION OF SYMPTOMS:

Mental general:
Mildness of mind

Physical General:
General > covering
> fanning
Aversion meat

Particular:
Pain limbs < night
> hanging down the limbs
Ulcer on foot
Chest pain with sweating

MIASMATIC EXPRESSION :
PSORA     SYCOSIS       SYPHILIS

Pespiration during pain    Ulcer on foot
Tuberculosis                  Aversion meat
Angina                           Tuberculosis
                                  Arteriosclerosis

REPERTORISATION:
Rubrics selected (Kent’s repertory) :
1. Mind – mildness
2. Stomach – Aversion, Meat
3. Generalities – tobacco, agg.
4. Extremities – Hang down, letting limbs, amel.
5. Chest – Phthisis pulmonalis
6. Chest – Angina pectoris.
7. Extremities – Ulcers foot.
Repertorial result :

Ars - 16/6
Phos - 15/7
Puls - 15/6
Lyco - 13/7
Sil - 13/6
Sulph - 12/6
Kali c - 11/6
Rhus tox - 11/5
Spongia - 11/4
Sepia - 10/6

PDF:
Generalities : Stone- cutters for- Calc3, Sil3, lyc2, puls2 ,ipecac1,
nat c1, nit ac1, phos ac1, sulph1

PRESCRIPTION AND FOLLOW UP :
11-02-04 Lach 0/3 -2d
12-02-04 Lach 0/3-2d
13-02-04 No relief of coplaint, sleep reduced Secale cor 30-2d
14-02-04 Slight relief Secale cor 30-2d
15-02-04 Secale cor 30-2d
16-02-04 No change Secale cor 30-2d
17-02-04 Pain < ed Secale cor 30-2d
19-02-04 Syphilinum 1M -2d
20-02-04 Slight relief SL - 2d
26-02-04 Pain limb < night Secale cor 30 -2d

Daily cleaning and dressing with Echinacea is done.

ARTERIAL STENOSIS OR ARTERIAL OCCLUSION OF LOWER LIMB

Symptoms and signs of lower limb arterial stenosis:

1. Intermittent claudication : It is a cramp like pain felt in the muscles
brought on by walking not present on taking first step. It is relieved by standing still. Distance walked is called claudication distance.
2. Rest pain is severe pain felt in the foot at rest, made worse by lying down or elevation of foot. This pain is worse at night, may be somewhat relieved by hanging the foot out of bed, or by sleeping in a chair.
3. Coldness, numbness and paraesthasia.
4. Colour changes : Moderate or severely ischaemic limbs become blanched on elevation and develop a bluish – purple discolouration on dependency.
5. Ulceration and gangrene : Occurs with severe arterial insufficiency and often presents as a painful superficial erosion between toes or small, shallow indolent non-healing ulcer, may occur on the dorsum of the feet, on the shin and especially around the malleoli.
6. Temperature : Severely ischaemic limbs are usually cold.
7. Sensation and movement : Acutely ischaemic limbs are frequently paralytic without sensation. Severe chronic ischaemia does not produce paralysis, but hyperaesthesia is common, especially in those areas of skin on the borderline of gangrene.
8. Arterial pulsations : Arterial pulsations below an occlusion in a main artery are absent or diminished.
9. Arterial bruits : A systolic bruit over the occluded artery is due to turbulence.
10. Venous refilling : the limb should be elevated for 30 seconds and then laid flat on the bed. Normal refilling occurs within seconds. Reduced venous filling is due to obstruction.
11. Harvey’s sign : If the two index fingers are placed firmly side by side on a vein and the finger nearer to the heart is moved so as to empty a short length of vein. The release of the distal finger will allow venous filling. The speed of venous refilling is to be observed. Will be slow if there is any obstruction.
12. Impotence : In male patients with an occlusion in the region of the bifurcation of the aorta and the internal iliac arteries. (Leriche’s syndrome).

Relationship of clinical findings to site of disease:
Aorto – iliac obstruction : Claudication in both buttocks, thighs and calves.
Femoral and distal pulses absent in both limbs.
Bruit over aorto-iliac region.
Impotence common.
Iliac obstruction : Unilateral claudication in thigh and calf and
sometimes buttocks.
Bruit over iliac region.
Unilateral absence of femoral and distal pulses.
Femoro- popliteal : Unilateral claudication in calf.
obstruction Femoral pulse palpable with absent unilateral distal pulses.
Distal obstruction : Femoral and popliteal pulses palpable.
Ankle pulses absent.
Claudication in calf and foot.

Classification of arterial stenosis is based on causes: can be broadly classified into large artery occlusion and small artery occlusion.

Causes ischaemia can be classified as follows.
Large artery occlusion Small artery occlusion
1. Chronic – Atherosclerosis 1. Buerger’s disease (TAO)
2. Acute – Embolism 2. Raynaud’s disease
Trauma 3. Embolism
4. Diabetes
5. Scleroderma
6. Physical agents – Trauma, radiation, electric burns, pressure necrosis.

LARGE ARTERY OCCLUSION
This may manifest either as chronic obstruction or acute obstruction

I PERIPHERAL ATHEROSCLEROTIC DISEASE : (Arteriosclerosis obliterance) : Most persons with occlusive arterial disease have an underlying atherosclerotic process. Clinical syndromes depend upon the extent of obstruction, how rapidly it progresses, what particular vessel is involved and whether an adequate collateral flow occurs. Common in patients above 50 years.
Atherosclerosis is a slowly progressive disease characterized by focal formation of atheromata in the intima of muscular arteries, primarily those of large and medium sized. It is composed of cholesterol, cholesterol esters, smooth muscle cells and a covering of fibrous plaques. Its growth causes a reduction in blood flow of affected areas of the vessel wall.

Risk factors are,
Hyperlipedemia – Hypercholesteraemia, Hyperglyceridaemia, hyperproteinaemia especially LDL
Hypertension
Cigarette smoking
Diabetes mellitus
Obesity
Physical inactivity
Genetic factors
Diet
Age
Hormonal factors
Psychological stress

II ACUTE ARTERIAL OBSTRUCTION:
Acute ischaemia is caused by sudden arterial occlusion by embolisation from the heart, a proximal atherosclerotic plaque or an aneurysm or by an acute thrombosis on preexisting atherosclerotic disease. Commonly due to emboli, trauma or arterial thrombosis.

i) Arterial embolus : An embolus is a body which is foreign to the blood-stream and which may become lodged in a vessel and causes obstruction.

Two types of embolisation may occur.
1) Cardio-arterial embolisation 2) Arterio-arterial embolisation

1) Cardio-arterial embolisation occurs in majority of cases of emboli in the lower extremity and such emboli originate in the heart either due to arterial fibrillation, mitral stenosis or myocardial infarction.

2) Arterio-arterial embolisation originates from atherosclerotic plaque which has been ulcerated. In the lower extremity emboli usually lodge at the bifurcation of common femoral artery or at the bifurcation of popliteal artery or at the bifurcation of aorta in order of frequency. In upper limb common site is at the bifurcation of the brachial artery followed by the axillary artery near shoulder joint.

ii) Arterial trauma : May also cause acute arterial occlusion.

The causes are,
1. Most arterial injuries result from penetrating wounds which partly or completely disrupt the walls of the arterias.
2. Pressure on a major artery by an angulated bone.
3. Intimal rupture of a major artery due to fracture or dislocation.
4. Injury to a major artery by a bone fragment.
5. Fractures and dislocation which may cause acute arterial occlusion like - supracondylar fracture of humerus, supracondylar fracture of femur, dislocated shoulder, dislocated elbow, dislocated knee.

iii Acute arterial thrombosis : The most common site is the lower end of the femoral artery where it leave sub sartorial canal to enter the popliteal space. Commonly acute thrombosis occurs in an artery considerably narrowed by arterial disease.
Clinical features :
The clinical features of acute arterial occlusion are best described by 5 P’s – Pain, Paralysis, Paraesthesia, Pallor and absent Pulse.

SMALL ARTERY OCCLUSION :

i. Thrombo angitis obliterance (Buerger’s disease) : It is an inflammatory reaction in the arterial wall with involvement of neighbouring vein and nerve terminating in thrombosis of the artery. The usual victims of this disease are young men below 40 years of age. The lower limbs are commonly involved. The lesions in Buerger’s disease are segmented and usually begin in arteries of small and medium size. In lower extremity the disease generally occurs beyond the popliteal artery, starting in tibial arteries extending to the vessels of the foot. Early in the course of Buerger’s disease the superficial veins are involved producing the characteristic migratory, recurrent superficial phlebitis. The disease has a striking association with cigarette smoking. Majority of patients of Buerger’s disease come from lower socio-economic groups. An autoimmune aetiology has been postulated and familial predisposition has been reported.

Clinical features:
The usual signs and symptoms of arterial occlusive disease will be present.
Pedal arteries are involved first and the patients complain of pain while walking at the arch of the foot (foot claudication). Gangrene of toes and fingers are common. Buerger’s test will be positive.
Characteristic arteriographic appearance of this disease is the smooth and normal appearance of larger arteries combined with extensive occlusion of the smaller arteries along with extensive collateral circulation.

ii. RAYNAUD’S DISEASE :
Usually occurs in young women and affects the upper extremities more than the lower. The peripheral pulses are normal. The condition is attributable to abnormal sensitivity in the direct response of the arterioles to cold. When cooled the vessels go into spasm and as a result the part becomes blanched and incapable of finer movements – this stage is called stage of local syncope. This is followed by second stage called local asphyxia – in this the white digits turn blue with burning sensation, this is due to slowing of circulation and accumulation of reduced haemoglobin. In the third stage the bluish discolouration gradually disappears and the digits regain normal colour due to release of spasm of digital arteries. Such attacks are repeated, till in the end patches of superficial ulceration and gangrene appear at the finger tips which is known as local gangrene.

Treatment : Conservative type of management like protection from cold, avoidance of pulp and nail bed infection and use of vasodilator drugs.
Sympathectomy : Immediate results of sympathectomy are good. But after a few months the susceptibility to cold returns.
Palliative procedure : Preganglionic section of the thoracic spine.

Raynaud’s phenomena : Peripheral vasospasm occurring secondary to other organic diseases such as atherosclerosis, collagen diseases especially scleroderma, Buerger’s disease, cervical rib, following use of industrial tools (drills) etc.
Treatment : treat the cause.

iii. DIABETES MELLITUS :
Development of gangrene is quite commonly seen in diabetic individuals. There are three factors in causing diabetic gangrene,
1. Atherosclerosis of the peripheral arteries.
2. Peripheral neuritis interfering with trophic function.
3. diminished resistance to trauma and infection of the sugar-laden tissue. The gangrene is usually moist due to infections. (eg. Fungal infection).

INVESTIGATIONS OF ARTERIAL STENOSIS :
1. Blood : R/E , Wasserman reaction (for syphilitic endarteritis obliterance), sugar, urea and electrolytes. If atherosclerosis is suspected estimation of serum β-lipoprotein, triglycerides and cholesterol should be done.
2. Urine : R/E to know whether the patient is diabetic or not and to know the renal vascular insufficiency.
3. Plain X-ray : Helpful to diagnose,
i) Arteriosclerosis with presence of arterial calcification.
ii) Aneurysm with flecks of calcium to outline it.
iii) Gas gangrene with presence of gas as dark spots in soft tissue.
iv) Cervical rib.
4. E.C.G. – abnormal E.C.G. in coronary artery involvement.
5. Arteriography : this is the most reliable method of determining the state of the main arterial tree. This procedure gives information about the size of the lumen of the artery, the course of the artery, constriction and dilatation of the arteries and the condition of the collateral circulation. Hypaque 45 (Sodium Diatrizoate) is the contrast medium often used.
Two types of arteriography – Retrograde percutaneous catheterization and direct arterial puncture.
6. Determination of blood velocity by ultrasound Doppler effect. This apparatus can be used to measure blood pressure at ankle and at the arm. Normally the ankle systolic blood pressure is greater than the branchial systolic BP by 5 to 15mm. So, the ratio of the ankle BP and arm BP will also be greater than one and known as ‘pressure index’. If it is less than one, it indicates some degree of arterial occlusion when the ankle BP goes down to 30 mm of Hg or less – indicates severe ischaemia.
7. Isotope technique using Xenon 133 or Technitium 99.
8. Plethysmography.

MANAGEMENT OF ARTERIAL STENOSIS :
1. Conservative methods.
a) Adjustment of life style.
b) Stopping smoking.
c) Taking regular exercise within the limits of the pain.
d) Diet – to reduce weight in the obese and more specifically in the treatment of hyperlipidaemia.
e) Oral vasodilator drugs.
f) Diabetes and hypertension should be treated properly.
g) Care of the feet.
h) Heel raise : Cllaudication distance may be increased by raising the heels of the shoes by 1 cm.-the work of the calf is reduced thereby.
i) Elevation of the head of the bed.
j) Buerger’s exercise : Repeated 2 minutes elevation and dependency of the limb.
k) Sympathectomy is not very effective in cladication but can relieve rest painand ulceration because the effect is mainly on the skin and subcutaneous vessels.
l) Chemical sympathectomy is an alternative method using lignocaine 1% and phenol.

2. Surgical management
Indications for surgery:
1. Claudication is a relative indication for surgery – ie, relative to the patient’ need.
2. Rest pain is an absolute indication.
3. Ischaemic ulceration that does not respond to conservative metods. Urgent surgery may be indicted in rapid deterioration of an already ischaemic limb to prevent limb amputation.

Different types of surgery:
I Aorto iliac artery stenosis – aortofemoral bypass or iliac endarterectomy.
In patients who are unfit for surgery balloon trans-luminal angioplasty is done
II Superficial femoral and profunda femoris artery stenosis – femoro popliteal bypass graft.
III Stenosis below the popliteal artery – Sympathectomy eg, in those patients with TAO and diabetes.
The long term results of aorto iliac reconstructive surgery are excellent and femoro-popliteal surgery is less successfully.

Amputation:
Amputation should be considered when part of a limb is dead (gangrene), deadly (moist gangrene – severe toxaemia and systemic infection) or dead loss (severe laceration and fracture accidents)

Types
i) Distal (minor) amputation – amputation of toe.
ii) Trans – metatarsal amputation – if several toe are affected and irreversible ischaemia has extended to the forefoot.
iii) Major Amputation
a) Below knee amputation
b) Above knee amputation

Homoeopathic medicines:
Antracinum, Arn, Ars alb, Carb ani, Carb v, Echinacea, Lach, Secale, Sulph ac, Tarent cub,
Rubrics for arterial stenosis in Kent’s repertory:
Extremities, Pain, Calf, Walking <
Extremities, Gangrene
Extremities, Ulcers
Generalities, Tobacco, agg.
Rubrics for arterial stenosis in Boricke’s repertory:
Circulatory system , Arteries, Atheroma of arteries – Arteriosclerosis, 35 drugs are given
Clarck Clinical Repertory :
Arteriosclerosis – Plb i 2