A 52-Year-Old Woman With Diabetes and Claudication

DR DALEY: Mrs D is a 52-year-old mother of 2 children who has progressive pain in her right leg while walking. She lives in Boston and has her health care insurance through Massachusetts Medicaid and Medicare. MrsDhashadinsulin-dependentdiabetesmellitusfor29years, complicated by peripheral neuropathy, retinopathy, and nephropathy with nephrotic range proteinuria. She has had 1 atrophic kidney since childhood and has required chronic hemodialysis since June 1997. She has had hypertension since age 16 years.Thepatienthas long-standingcoronaryarterydiseasewith ahistoryof2myocardial infarctions.Shehadpercutaneoustransluminal angioplasty for chronic angina without relief, followed by coronary artery bypass graft for triple vessel disease, including significant stenosis of the left anterior descending artery, in June 1997. She had an episode of congestive heart failure in 1995 with an ejection fraction of 0.25. She has hyperlipidemia and has tried several lipid-lowering agents, but has been unable to tolerate them because of adverse effects. Most recently she discontinued treatment with gemfibrozil because of gastrointestinal side effects. She has an 80 pack-year history of smoking and stopped smoking in the summer of 1997. Family history is significant for her father who died of coronary artery disease at age 53 years and for her mother who had diabetes mellitus, coronary artery disease, and renal failure requiring dialysis. Mrs D also has temporal lobe epilepsy and has experienced several episodes of major unipolar depression requiring hospitalization. She has a multinodular goiter and is euthyroid. She has a history of peptic ulcer disease, chronic gastroparesis, and gastroesophageal reflux disease with severe, chronic nausea. Despite her multiple, chronic illnesses, Mrs D has been an avid sportswoman and athlete since childhood. In the spring of 1997, she noted right calf pain and cramping when running to first base during softball games. She then developed progressive pain in her right leg after walking 25 to 35 ft. She notes the onset of pain after walking for 1 minute, and after walking 25 ft, describes the pain as severe. The pain limits her activities; for example, she now parks closer to her destinations because she cannot walk more than 10 to 25 ft without experiencing disabling pain. She has no rest or nocturnal pain. Her current medications include furosemide (80 mg daily), metoclopramide hydrochloride (10 mg daily), NPH insulin, aspirin (325 mg daily), cisapride (10 mg 4 times daily), phenytoin (100 mg 3 times daily), metoprolol tartrate (50 mg twice daily), and epoetin alfa on dialysis. On physical examination, Mrs D is pale and appears chronically ill but not depressed. Vascular examination is significant for bilateral carotid bruits and an absent right popliteal and pedal pulse. Vascular access for dialysis has been placed in both arms. Laboratory examination is significant for the following levels: serum urea nitrogen, 30.3 mmol/L (85 mg/dL); creatinine, 522 μmol/L (5.9 mg/dL); random blood glucose, 9.1 mmol/L (164 mg/dL); fasting total cholesterol, 5.61 mmol/L (217 mg/dL); high-density lipoprotein, 1.32 mmol/L (51 mg/ dL); low-density lipoprotein, 3.57 mmol/L (138 mg/dL); triglycerides, 1.58 mmol/L (140 mg/dL); and hematocrit, 0.33. Noninvasive studies of her carotid arteries show a 60% to 69% stenosis of the left carotid artery. Pelvic contrast magnetic resonance angiography showed a 70% stenosis of the left common iliac artery, 30% to 40% stenosis of the right common iliac artery, and an occlusion of the right popliteal artery just above the knee joint. Lower-extremity magnetic resonance angiography showed an obstruction of the distal right superficial femoral artery about 8.5 cm above the knee joint with good reconstitution. The trifurcation and the remaining vascular structures of the lower extremities appear normal. A vascular surgeon diagnosed claudication in her right leg secondary to superficial femoral artery disease and recommended surgery. A trial of exercise was unsuccessful because Mrs D developed leg pain so severe she was unable to walk and angina. Mrs D has largely recovered from her coronary bypass surgery, aside from some vascular access problems, and she is awaiting surgery for claudication.