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Ischemic pain is pain caused by obstruction of the circulation to a body part. Pain management centers have only recently become involved in the care of patients with ischemic diseases such as peripheral vascular disease and angina pectoris because now these centers have something unique to offer. This chapter provides a review of the pathophysiology of ischemic disease, the therapies available and their efficacy, and the role of the pain specialist in the management of patients with peripheral and coronary ischemic disease.

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Atherosclerosis obliterans is the principal cause of ischemic pain associated with peripheral vascular disease and coronary artery disease. Ischemic pain in peripheral vascular disease is insidious and gradual in onset. It usually begins with intermittent claudication. Most patients have atherosclerotic changes for 5 to 10 years before they have symptoms. Approximately 25% of patients with intermittent claudication will progress to critical ischemia and pain at rest.

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Intermittent claudication is the earliest sign of vascular insufficiency, which is characterized by cramping, tightness, and heaviness that increases with exercise. The pain is relieved with rest and the claudication distance remains fairly constant until further progression of the disease. In the early stages of the disease, collateral circulation develops and may maintain adequate perfusion to the affected limb, but may not provide sufficient blood flow to prevent symptoms, especially during exercise. Over time, both the primary and collateral vessels become stenotic or occluded and critical ischemia develops with pain at rest.

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The most common sites of atherosclerosis obliterans are the femoropopliteal arterial segment and the aortoiliac vessels, causing pain in the calves and buttocks, respectively. With progression of the disease, gangrene, ischemic ulcers, and trophic changes can occur in the more distal locations, namely the distal foot and toes. Ischemic ulcers can occur spontaneously; however, trauma is usually the inciting event leading to ulcer formation. The injury is unable to heal due to poor perfusion. Trophic changes, specifically dry scaly skin, loss of hair, and thick nails are also a sign of arterial insufficiency.

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Conservative therapy for treatment of intermittent claudication includes smoking cessation and the control of contributing diseases such as hypertension, diabetes, and hyperlipidemia. Protective and prophylactic care of the feet including good hygiene, avoidance of trauma, pressure points, and poorly fitting shoes is imperative to prevent ischemic ulceration and gangrene. Keeping the feet clean, dry and free of infection is also important. In spite of these measures to slow the progression of atherosclerotic occlusive disease, 25% to 50% of patients will require more aggressive treatment

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Ischemic pain is described as an achy and crampy sensation that is worse at night and improves when the legs are in a dependent position, which improves blood flow. When rest pain occurs, the degree of vascular insufficiency is severe and these patients are also at increased risk for diffuse atherosclerotic disease of the coronary and cerebral arteries. The differential diagnosis for intermittent claudication is ...

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