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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 ...