Chronic wound and postamputation claudication pain in a diabetic patient.

Underlying ischaemic disease should be excluded in patients with delayed wound healing. Contrast angiography is a useful imaging method for assessing the specific cause of wound chronicity and may also be helpful in assessing the aetiology of unexplained pain symptoms. Angioplasty provides a practical alternative to more invasive techniques in addressing peripheral ischaemia. Our patient suffered claudication-type pain in his thigh and a non-healing stump wound following below-knee amputation. Magnetic resonance angiography confirmed the presence of arterial stenoses and an angioplasty was successfully performed to improve patency of the profunda femoris vessel. Following the operation, the claudication pain symptoms were significantly reduced and the stump wound went on to heal.

Underlying ischaemic disease should be excluded in patients with delayed wound healing. Contrast angiography is a useful imaging method for assessing the specific cause of wound chronicity and may also be helpful in assessing the aetiology of unexplained pain symptoms. Angioplasty provides a practical alternative to more invasive techniques in addressing peripheral ischaemia. Our patient suffered claudication-type pain in his thigh and a non-healing stump wound following below-knee amputation. Magnetic resonance angiography confirmed the presence of arterial stenoses and an angioplasty was successfully performed to improve patency of the profunda femoris vessel. Following the operation, the claudication pain symptoms were significantly reduced and the stump wound went on to heal.
Diabetes prevalence has risen to almost 10% worldwide. 1 The lifetime risk of foot ulcers in this group is 15% 2 and diabetic foot ulcers are a significant cause of amputation. 3 Delayed wound healing and pain are important consequences of amputation, especially in diabetic patients. 4 Resolution of the stump wound is particularly impaired in diabetic patients by infection, diabetic neuropathy and continued trauma, defects in matrix turnover and angiogenesis, and, significantly, deficient blood supply due to diabetic arteriopathy. Treatment is directed at glycaemic control, wound care and promotion of healing. Both surgical revascularisation and angioplasty are useful procedures but bypass may be contraindicated, especially in patients with significant co-morbidities or when the stenosis is located abdominally.
Pain is an important consequence of amputation. Particularly well documented is phantom limb pain, where discomfort is perceived at a site distal to the amputation. Treatment consists of pharmacological interventions such as ketamine, prosthesis use and psychological approaches. Additionally, neuropathic pain may follow operation. This is treated with gabapentin, the 5% lidocaine patch, opioid analgesics, tramadol hydrochloride or tricyclic antidepressants. Duloxetine is of use in patients with painful diabetic neuropathy. Less familiar is pain with a claudication character although this may be an important complication.
Cilostazol and pentoxifylline are useful medications but may provide insufficient relief.
We present a case of a non-healing wound and claudication-type pain in the thigh following below-knee amputation, imaged with contrast angiography and treated using angioplasty. The outcome was successful, and resulted in wound resolution and reduced pain.

case history
A 67-year old male diabetic patient presented to a specialist clinic with a non-healing stump wound and claudicationtype pain in his left thigh, following left below-knee amputation. He had previously undergone bypass surgery in an attempt to revascularise his lower limb.
Magnetic resonance angiography revealed left noncritical iliac stenosis, critical profunda femoris stenosis and a blocked femoropopliteal bypass graft (Fig 1). The patient was reviewed in a specialist multidisciplinary clinic, which included a vascular surgeon, a vascular interventional radiologist, a diabetologist and a wound healing specialist. It was decided that angioplasty to the profunda femoris stenosis could increase blood flow to the affected limb, improving symptoms and healing.
The treatment option and associated risks were explained to the patient. He was advised of the potential for WARNER RiCHARdS BiSWAS CHiCK LEWiS HARdiNg chronic wound and postamputation claudication pain in a diaBetic patient irreparable blood vessel damage and the need to convert to an above-knee amputation but he felt that symptoms were severe enough to necessitate intervention. Angioplasty offered the best chance of improving blood supply and could also potentially be repeated with minimal risk should symptoms redevelop. A successful outcome would usefully confirm the cause of the symptoms. The patient underwent a left profundoplasty procedure as a day case. The right  common femoral artery was accessed and a 5Fr bright tip crossover sheath was placed. The stenosis was crossed easily using a Terumo guidewire (Egham, UK) and successful angioplasty was performed using a standard Cook 0.035" 5mm balloon (Bloomington, IN, US) (Fig 2). Figures 3 and 4 show pre-and post-procedure blood vessel calibre. Following the operation, the pain symptoms and wound healing improved significantly. Clinical follow-up was recommended to monitor future development of pain.

discussion
Peripheral angioplasty is recognised as a good revascularisation option in diabetic patients. It aims to increase blood flow sufficiently to relieve pain and heal skin lesions. This procedure provides good symptomatic relief and is associated with low morbidity. Although open bypass surgery remains the best long-term option in treatment of stenoses to ensure continued patency, percutaneous interventions are often advantageous due to their minimally invasive nature. In addition, the procedure can be repeated if symptoms reoccur, without the additional morbidity risk of repeat surgery. The main limitation of angioplasty is its inefficacy in vessels completely occluded by calcification.
Profunda femoris stenoses are less common than those of the infrapopliteal arteries but they are more common in diabetic patients. Cross-sectional imaging such as magnetic resonance peripheral angiography or computed tomography is useful in visualising the vessel lumen, and can guide interventions and planning. Catheter angiography, however, remains the most accurate technique for assessing arterial stenoses. It can proceed directly to treatment, and recent improvements in peripheral angioplasty technique and equipment have broadened the potential for its use. It is a valuable technique in both occlusive and tibial disease, which are particularly prevalent in a diabetic population.

conclusions
In this case, a man presented with claudication-type pain in his thigh and a non-healing stump wound following amputation. Angiography was undertaken to assess blood vessel calibre and stenoses in the profunda femoris artery were identified. An angioplasty was performed successfully. In cases of this nature, pain symptoms would normally be ascribed to phantom limb pain. However, improvements in cross-sectional imaging and angiography make it possible to assess the situation more accurately. Bypass surgery has formerly been a useful treatment option but new developments in angioplasty techniques allow stenotic lesions to be addressed with minimal invasiveness.
Our case highlights the use of imaging and the importance of taking a good history to clarify the nature of a patient's symptoms. This facilitates informed decision making regarding treatment options and the potential for continued support. With new surgical techniques, it is possible to consider alternative and repeatable interventions in patients whose symptoms return. references