CHRONIC LOWER LIMB ISCHEMIA

ANATOMY

1. Aortoiliac segment (inflow)

2. Femoropopliteal segment

3. Infrapopliteal segment (outflow)

INTRODUCTION• Chronic Limb ischemia

= Decrease in limb perfusion > 2 weeks2007 Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)

• Aetiology: Atherosclerosis (90%)• May present at any point along a scale of

severity:

Mild Intermittent Claudication

Rest pain

Ischaemic skin changes

Gangrene of large part of limb

** 2 distinct entities:

Intermittent claudication

(IC)

Critical Limb Ischaemia

(CLI)

(A) INTERMITTENT CLAUDICATION5% people over 60 y.o.

(only 1-2% deteriorates)

Ddx: neurogenic; venous claudication

Definition of IC- Muscular pain

- Not present at rest- Comes on walking a particular distance (claudication distance)- Quickly relieved by resting- Repetitive

Mx: Best Medical

Therapy (BMT) – risk factor

modificationSurgical/

endovascular intervention only

after 6 month compliance to BMT

CRITICAL LIMB ISCHEMIA• Multiple lesions affecting different arterial segments• Features:

– Rest pain– Tissue loss (ulcer/gangrene)– Low Ankle Brachial Pressure Index (<0.5)

• Fontaine III & IV

ISCHEMIC ULCERS VENOUS ULCERS

PAIN Yes, unless neuropathic Minimal; not intolerable

DURATION Less than 6 weeks Often months/years

PAST HISTORY Cardiac ischemia/CABG common

DVT/ severe varicose veins

LIMB SIGNSSWELLING Not swollen unless pt has

been sleeping in a chair to relieve pain

Usually non-pitting plus pitting edema unless effective bandaging in place

TEMPERATURE Usually cold Usually normal or warm

PULSES Absent; low Doppler pressure *ABSI/ABPI

Present; normal Doppler pressure

ULCERSSITE Toes, dorsum of foot Gaiter’s area

MARGIN Punched out Irregular with blue margin & growing epithelium

BASE Destroy deep fascia & may expose tendons, with poor granulation

Beefy red, shallow and never penetrate deep fascia, pale granulation tissue

MANAGEMENT

NON- SURGICAL MANAGEMENT

Pharmaco Non-pharmaco

SURGICAL MANAGEMENT

Minimally invasive Invasive

Stop smoking

Hypertension control

Hypercholesterolemia control

Antiplatelet agent

Regular exercise

Obesity control

Diabetes identification

& active treatment

Foot care

Best Medical Therapy (BMT)

-endaarterectomy-Balloon angioplasty with/without stenting

-Bypass surgery (arterial reconstruction)- Amputation

Buerger’s DiseaseNon-atherosclerotic, idiopathic,

recurrent, segmental inflammatory, vasculopathy of

medium & small sized arteries & veins of upper & lower extremities

Diabetic FootCombination of ischemia,

neuropathy, & immunocompromise that renders the feet of diabetic pt susceptible to sepsis, ulceration & gangrene.

Challenges in diabetic vascular disease:- Calcified- Reduce ability to fight infection- Multisystem - Infrapopliteal vessels- Co-existing neuropathy

REFERENCES• Principles & Practice of Surgery• Essentials Surgery• Inter-Society Consensus for the Management of Peripheral Arterial

Disease (TASC II), L. Norgren et. al., Eur J Vasc Endovasc Surg Vol 33, Supplement 1, 2007

• Review Articles: Critical limb ischemia, Varu et. al., Journal of Vascular Surgery, 2010

• Chronic lower limb ischemia, J.D. Beard, BMJ 2000