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Unless there are associated lesions in the aorto-iliac or femoral/SFA segments, claudication may not be evident The gastrocnemius and soleus muscles may receive adequate blood supply from collateral vessels from the popliteal artery; therefore, when disease is isolated to the tibial vessels, there may be foot ischemia without attendant claudication, and rest pain may be the first sign of severe vascular insufficiency Classically, rest pain is confined to the dorsum of the foot at the area of the metatarsal heads and is relieved with dependency Because of the high incidence of neuropathy in these patients, it is important to differentiate rest pain from neuropathic dysesthesia If the pain is relieved by simply dangling the foot over the edge of the bed, which increases blood flow to the foot, then the rest pain is due to vascular insufficiency The pain is severe, usually burning in character and will awaken the patient from sleep On examination, depending on whether associated proximal disease is present, there may or

Sales Documents | Contracts | Contract Data | Control Cancellation Define Cancellation Reasons Here one simply defines the cancellation reason, which may also be used to report on sales analyses Define Cancellation Procedures This description of configuration task in the IMG relates to the Figure 4-7, which shows the cancellation procedure validity Define Cancellation Rules Here the rules of the cancellation procedure are defined For example, in Figure 4-8, the rule 0001 takes the contract cancellation baseline date as the start date of the contract It then set the rule valid to 12, which is a date rule meaning one week Within that period of one week, the contract may then be cancelled on any day up to the last day of the one-week period (The notice value is 1 and the unit is day, therefore the contract may be cancelled up to one day before the end of the week) The system uses these settings to automatically enter the validity period and date determination in the contract This is done by assigning the contract profile to the sales document type representing the contract, for example, WV

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Open surgical procedures of the lower extremity, particularly long bypasses with vein harvest, have a risk of wound infection that is higher than in other areas of the body Leg infection or seroma can occur in as many as 15 20% of cases Myocardial infarction rates after open surgery are 5 10%, with a 1 4% mortality rate Complication rates of endovascular therapy are 1 5%, making these therapies attractive despite their lower durability

The prognosis for motivated patients with isolated SFA disease is excellent, and surgery is not recommended for mild or moderate claudication in these patients However, when claudication significantly limits daily activity and

may not be femoral and popliteal pulses, but the pedal pulses will be absent Dependent rubor may be prominent with pallor on elevation The skin of the foot is generally cool, atrophic, and hairless

Sudden pain in an extremity Generally associated with some element of neurologic dysfunction with numbness, weakness, or complete paralysis Absent extremity pulses

The ABI may be quite low (in the range of 03), but ABIs may be falsely elevated because of the noncompressability of the calcified tibial vessels Wave-form analysis is important in these patients with a monophasic flow pattern denoting critically low flow Segmental pulse volume recordings will show a fall-off in blood pressure between the calf and ankle, although pulse volume recordings also may also be affected by tibial vessel calcification

Acute occlusion may be due to an embolus or to thrombosis of a diseased atherosclerotic segment Arterial to arterial emboli such as in the cerebrovascular tree can occur, but emboli large enough to occlude proximal arteries in the lower extremities are almost always from the heart and tend to lodge at the bifurcation of major arteries Over 50% of the emboli from cardiac sources go to the lower extremities, 20% to the cerebrovascular circulation, and the remainder to the upper extremities and mesenteric and renal circulation Atrial fibrillation is the usual cause of the thrombus; other causes are valvular disease or ischemic heart disease where thrombus has formed on the ventricular surface of a transmural myocardial infarct Emboli from arterial sources such as arterial ulcerations or calcified excrescences are usually small and go to the distal arterial tree (toes) The typical patient with primary thrombosis has had a history of claudication and now has an acute occlusion If the stenosis has developed over time, collateral blood vessels will develop, and the resulting occlusion may only reduce walking distance or cause minimal increase in symptoms

Good foot care may avoid ulceration, and most diabetic patients will do well with a conservative regimen However, if ulcerations appear and there is no significant healing within 2 3 weeks, revascularization will be required Infrequent rest pain is not an absolute indication for revascularization However, rest pain occurring nightly with monophasic wave forms requires revascularization to prevent threatened tissue loss

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