What is the management for a patient with compressible veins in both lower extremities, rheologic stasis, venous insufficiency, and arterial occlusions in the right dorsal pedis artery and left posterior tibial artery and dorsal pedis artery?

Management of Mixed Arterial-Venous Disease with Bilateral Lower Extremity Involvement

This patient requires immediate vascular surgery consultation for arterial revascularization planning, with modified compression therapy (20-30 mm Hg) only after confirming ankle-brachial index (ABI) is >0.6, as the arterial occlusions pose immediate limb-threatening risk that takes priority over venous management. 1

Critical Initial Assessment

Determine the severity of arterial insufficiency first, as this dictates all subsequent management decisions:

• Obtain bilateral ABIs immediately to quantify arterial disease severity 1
• An ABI <0.6 indicates severe arterial insufficiency requiring urgent revascularization before any compression therapy 1
• Document presence of ischemic rest pain, tissue loss, or gangrene to classify as critical limb-threatening ischemia (CLTI) 1
• Assess for the "6 Ps" of acute limb ischemia: pain, paralysis, paresthesias, pulselessness, pallor, and poikilothermia 2

Arterial Disease Management (Primary Priority)

The arterial occlusions in the right dorsalis pedis artery (DPA) and left posterior tibial artery (PTA) and DPA require revascularization if causing symptoms or tissue loss:

Diagnostic Imaging

• CT angiography (CTA) of bilateral lower extremities is the preferred initial imaging modality, providing rapid comprehensive anatomic detail for revascularization planning 2
• CTA evaluates the entire arterial circulation including below-knee and pedal arteries, identifying both the level of occlusion and underlying atherosclerotic disease 2

Revascularization Strategy

• Endovascular intervention is the first-line approach for most patients with infrainguinal arterial occlusive disease 1
• Stenting can be useful in the femoral, popliteal, and tibial arteries as salvage therapy for suboptimal balloon dilation results 1
• Surgical bypass with autogenous vein is superior to prosthetic grafts for below-knee popliteal or tibial vessel reconstruction, with 5-year patency rates of 70% versus 27% for prosthetic materials 1
• The least-diseased tibial or pedal artery with continuous flow to the foot should be used as the outflow vessel 1

Medical Therapy

• Initiate antiplatelet therapy (aspirin 100 mg daily) and continue indefinitely unless contraindicated 1
• High-intensity statin therapy targeting LDL-C <55 mg/dL 2
• Blood pressure control to <130/80 mm Hg 2
• Consider pentoxifylline 400 mg three times daily to improve blood flow properties and tissue oxygenation, though this does not replace definitive revascularization 3

Venous Insufficiency Management (Secondary Priority)

Compression therapy is the cornerstone of venous insufficiency treatment, but must be modified in the presence of arterial disease:

Compression Therapy Guidelines

• For ABI 0.6-0.9: Use reduced compression of 20-30 mm Hg, which is safe and effective for venous leg ulcer healing 1
• For ABI <0.6: Compression is contraindicated until arterial revascularization is performed 1
• For ABI >0.9: Standard compression of 30-40 mm Hg is appropriate for more severe venous disease 1
• Inelastic compression (Velcro devices or 3-4 layer bandages) is superior to elastic bandaging for wound healing 1

Additional Venous Interventions

• Duplex ultrasound of bilateral lower extremities should be performed to assess the deep venous system, great saphenous vein (GSV), small saphenous vein, and perforating veins 1
• If significant saphenous vein reflux (>500 ms) is documented, consider saphenous vein ablation after arterial revascularization is complete 1
• Compression sclerotherapy or wound care are equivalent alternatives for venous leg ulcers once arterial disease is addressed 1

Critical Pitfalls to Avoid

Never apply full compression (30-40 mm Hg) without first confirming adequate arterial perfusion (ABI >0.6), as this can precipitate acute limb ischemia in patients with significant arterial disease 1

Do not delay arterial revascularization to treat venous disease, as the arterial occlusions pose immediate risk of limb loss, whereas venous insufficiency is a chronic condition 1, 2

Avoid using the deep veins (superficial femoral or popliteal veins) for bypass conduit harvest, as this causes severe venous stasis complications including phlegmasia, particularly when popliteal vein is harvested below the knee 4

Monitoring and Follow-up

• Patients who undergo lower extremity bypass should have periodic examinations for at least 2 years, including pulse examination and duplex imaging of the entire graft length 1
• Monitor for return of ischemic symptoms, wound healing progression, and graft patency 1
• Continue compression therapy indefinitely for venous insufficiency management once arterial perfusion is adequate 1
• Healing rates of 57% at 10 weeks and 75% at 16 weeks can be expected with appropriate compression therapy for venous ulcers 5