A 65-year-old man presents to the clinic with complaints of episodic burning pain involving the soles of his feet and toes. He reports symptoms are most severe when the weather becomes hot and generally occurs when he is outside in the heat. His feet and toes turn red and feel hot to touch during episodes. When he returns to an air-conditioned area, symptoms begin to dissipate or some episodes may take hours for complete resolution. Elevating his legs relieves symptoms as does walking barefoot on cold tile floors. His past medical history includes hypertension, well controlled with atenolol, and he takes once daily low-dose aspirin for primary prevention.
Physical Examination:
What laboratory values should be followed serially in patients with this condition?
Complete blood count with differential (CBC with diff). Patients with this condition should have a CBC with diff checked periodically for at least 2 to 3 years. It is important for treating physicians to recognize that erythromelalgia can precede the laboratory manifestations of a myeloproliferative disorder by up to 2 to 3 years.
Reference:
Creager MA, Dzau VJ, Loscalzo J, eds. Vascular Medicine: A Companion to Brunwald’s Heart Disease. Philadelphia, PA: Saunders; 2006:641–654.
A 17-year-old boy was involved in a motor vehicle accident, which resulted in multiple fractures as well as internal injuries that necessitated multiple abdominal surgeries over a 2-week period. He is expected to recover fully. An intraluminal filling defect was incidentally identified consistent with DVT of the right external iliac vein on a contrast-enhanced abdominal CT scan. Anticoagulation was contraindicated because of a retroperitoneal hemorrhage. It was determined that placement of an inferior vena cava filter was necessary.
Of the following types of filters, which filter is most appropriate in this case?
Gunther Tulip retrievable vena cava filter. This patient is young and his deep vein thrombosis is situational. He is expected to recover fully with no sequelae; thus he does not require placement of a permanent inferior vena cava filter. Proximal iliac thrombus in the setting of a hospitalized trauma patient following multiple abdominal surgeries is a very high-risk scenario for development of serious, life-threatening VTE. Anticoagulation is the treatment of choice when it can be safely administered; however, when contraindicated an inferior vena cava filter should be placed without delay. Patients with a temporary contraindication for anticoagulants should be reassessed at short intervals and, if circumstances permit, anticoagulants should be instituted for treatment of their VTE and to prevent recurrence. Of the filter types listed, only the Gunther Tulip is approved in the United States for retrieval. The OptEase is also approved for retrieval. The Bird’s Nest filter is the only filter available for use in patients with a so-called megacava (vena cava greater than 28 mm). The Bird’s Nest filter can be placed into an inferior vena cava of up to 42 mm in diameter. The TrapEase, Greenfield, and Simon Nitinol filters were not designed to have the option of retrieval.
Hann CH, Streiff MB. The role of vena cava filters in the management of venous thromboembolism. Blood Rev. 2005;19:179–202.
You are called to the bedside of a 68-year-old man in mild distress who underwent cardiac catheterization earlier in the day. He is complaining of increasing right groin pain. He complains of weakness and tingling in his foot and toes. He is presently on a heparin infusion because of atrial fibrillation. On inspection you note a large area of skin in his right groin and proximal thigh to be dark blue and there is a large, palpable, hard pulsatile mass. With ultrasound using color Doppler you note an irregular shaped area of flow measuring 4.0 cm × 3.3 cm near the common femoral artery, approximately 4.0-cm deep and connected to the artery by a 0.5-cm neck. There is surrounding hematoma observed. Spectral waveform analysis of the neck demonstrates a to-and-fro pattern.
What is the best treatment option for management of this patient’s condition?
Surgical evacuation of the hematoma and suture repair of the artery. The patient complains of developing numbness in the setting of developing a large hematoma and pseudoaneurysm. To relieve the compressive effect of the hematoma, prevent irreversible injury, and relieve pain, the most appropriate method of repair in this patient is to evacuate the hematoma. Most small to moderately sized pseudoaneurysms can be treated with either ultrasound-guided compression, thrombin injection, or when very small may be observed for spontaneous resolution. Placement of a femoral compression device (Fem-Stop) is not appropriate in this setting, and bandages should not be wrapped proximally around the thigh as this will cause worsening swelling and pain.
Creager MA, Dzau VJ, Loscalzo J, eds. Vascular Medicine: A Companion to Braunwald’s Heart Disease. Philadelphia, PA: Saunders; 2006:159–160.
A 74-year-old man is in the ICU (intensive care unit) recovering from coronary artery bypass surgery and has developed a hemorrhagic pericardial effusion. He is currently stable, but has noted swelling and pain in his left leg. An ultrasound is ordered and reveals acute thrombus in the left peroneal vein.
Which of the following is the best management option?
Follow up with serial duplex ultrasound scans. The peroneal vein is a calf vein with less propensity for clinically significant sequelae. Anticoagulant therapy for calf vein DVT is controversial. However, in this setting there is a clear contraindication to anticoagulate. Even prophylactic doses of anticoagulants are not advisable in patients with hemorrhagic pericardial effusions status post open heart surgery. Serial ultrasound scans have been studied as an alternative to anticoagulant therapy. If no propagation after several weeks, no anticoagulant therapy is necessary. If propagation occurs, then anticoagulation versus placement of an inferior vena cava should be considered.
Reference: The Sixth ACCP Conference on Antithrombotic and Thrombolytic Therapy: evidence-based guidelines. Chest Suppl. 2001;119:176S–193S.
A 25-year-old man presents to the clinic with complaints of pain in his feet with walking. He reports this has been going on for several months and has progressively worsened in the past few weeks. He is beginning to develop symptoms in his right calf and earlier this week noticed a black area on his great toe. He has no medical problems, takes no medications, and is in good health overall. He is a smoker and works as a computer salesman. He reports a family history of VTE; his mother had a pulmonary embolism at the age of 50 and was diagnosed with the antiphospholipid antibody syndrome.
What is the most likely cause of his symptoms?
Thromboangiitis obliterans (TAO, Buerger disease). TAO classically manifests in young, male patients with a recent history of heavy tobacco use. The clinical presentation is consistent with ischemia, beginning distally and involving the small- and medium-sized arteries. Usually the lower extremities are involved, with ischemia or claudication of the feet or legs. Foot or arch claudication is typical. Occasionally, the hands are involved. If the disease progresses with continued exposure to tobacco, patients are at significant risk for progressive ischemia, ulceration, gangrene, and eventually amputation. Antiphospholipid antibody syndrome is certainly possible, but it is not a hereditary condition and most often manifests with venous thrombosis. Takayasu arteritis does not usually present in this way. Nothing is suggestive of atrophie blanche, and premature atherosclerosis presenting in a 25-year-old man with claudication and ischemia would be highly unusual.
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