CHRONIC LIMB
ISCHAEMIA
MR HANIF HUSSEIN
CONSULTANT VASCULAR SURGEON, HKL
INTRODUCTION
• Chronic Limb Ischaemia
• Inadequate perfusion to the limbs
• Narrowing of the blood vessels in
the limbs
• Peripheral Vascular Disease
• Lower limbs > Upper limbs
• Range of symptoms
• Signs
• Absent pulses
• ABSI < 0.9
Vascular Update 2011
CRITICAL LIMB ISCHAEMIA
Vascular Update 2011
PERIPHERAL VASCULAR DISEASE
• Risk Factors
• Smoking
• Metabolic syndrome
• Diabetes mellitus
• Dyslipidemia
• Obesity
• Hypertension
• Gender
• Male > Female
• Age
• 3 – 10 % of all ages
• 15 – 20% over 70 year olds
Vascular Update 2011
PRESENTATION
PERIPHERAL VASCULAR DISEASE
• Symptoms
• Asymptomatic
• Early stage, mild disease
• Symptoms related to muscle activity/exercise
• Intermittent claudication
• Rest pain
• Non-healing ulcer Critical Limb
Ischaemia
• Gangrene
Vascular Update 2011
INTERMITTENT CLAUDICATION
• Leg pain sufficient to cause one to stop walking, which is
produced by exercise and relieved by rest, and is
caused by arterial occlusive disease
• Related to activity and life style
• One of the early symptoms of PVD
• But not necessarily early stage of disease
Vascular Update 2011
CRITICAL LIMB ISCHAEMIA
• Persistent, recurring ischaemic rest pain requiring
regular adequate analgesia for more than 2 weeks
- “Rest pain”
or
• Leg ulceration or gangrene of the foot or toes -
“Tissue loss”
with
• Ankle systolic pressure ≤ 50 mmHg or a toe systolic
pressure of ≤ 30 mm Hg
Vascular Update 2011
CRITICAL LIMB ISCHAEMIA
Vascular Update 2011
MANAGEMENT
MANAGEMENT
• Diagnosis
• History
• Physical Examination
• Bed-side non-invasive tests
• Investigations
• Assess lesion
• Plans for intervention
• Treatment
• Risk factor modification
• Revascularisation
• Rehabilitation
Vascular Update 2011
PHYSICAL EXAMINATION
• Examine the pulses
• Performed in only 6-11% of leg ++ Femoral art
examinations
• Peripheral Pulses
+
• Normal Popliteal art
• Weak
• Absent _ _ Post tib
Dorsalis
pedis
Vascular Update 2011
PHYSICAL EXAMINATION
• Hand-held Doppler
• Wave forms
Triphasic
• ABSI
• Ankle/Brachial systolic index
Biphasic
Monophasic
Vascular Update 2011
PHYSICAL EXAMINATION
ABSI = Ankle SP
Brachial SP
Vascular Update 2011
ANKLE BRACHIAL INDEX
ABSI Interpretation
> 1.1 Normal
Hardened / Non - compressible vessels*
0.9 – 1.1 Normal
0.7 – 0.89 Mild to moderate disease
(Asymptomatic to mild)
< 0.7 Moderate to severe disease
< 0.3 Critical limb ischaemia
*Calcified arteries in diabetics
Vascular Update 2011
NON-INVASIVE INVESTIGATION
• Toe pressure examination
• Photo plethysmography
• Distal perfusion in diabetic patients
Vascular Update 2011
INVESTIGATIONS
• Blood
• Full blood count
• Infection
• Polycythemia
• Blood sugars
• Lipid profile
• Renal profile
• Wound swab
• Cultures and sensitivity
• Imaging
• Foot X-Ray – Osteomyelitis
• MRI Foot – Soft tissue infection, OM
Vascular Update 2011
INVESTIGATIONS
• Imaging
• Level of stenosis/occlusion
• Distal run-off
• Plans for intervention
• Endovascular
• Open surgery
Vascular Update 2011
INVESTIGATIONS
• Imaging options
• Duplex scan
• CT angiography
• MRA
• DS angiography
Vascular Update 2011
TREATMENT
TREATMENT
• Multi-disciplinary team approach
• Physicians
• Vascular surgeons
• Interventional radiologist
• Orthopedic surgeons
• Plastic surgeons
• Dietician
• Physiotherapist
• Occupational therapist
• Podiatrists
Vascular Update 2011
INTERMITTENT CLAUDICATION
• Conservative treatment
• Non-debilitating claudication
• Not affecting life style
• Not affecting mobility
• Not affecting daily activity/work
• 3 – monthly reviews
• Monitor improvement/worsening of symptoms
• Monitor co-morbid factors
• Continuation of pharmacotherapy
Vascular Update 2011
CHRONIC LIMB ISCHAEMIA
• Treatment
• Risk factor modification
• Stop smoking
• Diabetic control
• Anti-platelet therapy
• Lipid lowering agents
• Exercise programmes
• 30 – 60 minutes, 3 x / week, 3 months
• Pain relief – anaelgesia
• Opiods
• Cox-2 inhibitors
• NSAIDS
Vascular Update 2011
CHRONIC LIMB ISCHAEMIA
• Indications for intervention
• Debilitating claudication
• Affecting lifestyle
• Limits mobility/activity
• Affects work
• Critical limb iscahemia
• Options for intervention
• Endovascular
• Angioplasty +/- stenting
• Open bypass surgery
• Hybrid
Vascular Update 2011
ANGIOPLASTY
• Indications
• Short segment lesions
• Patients not suitable for
bypass
• Age
• Co-morbid conditions
• With/without stenting
Vascular Update 2011
BYPASS SURGERY
• Indications
• Long segment stenosis
• Lesions at origin
• Configurations
• Aorto-bifemoral
• Ilio-femoral
• Femoro-popliteal
• Distal bypass
• Posterior tibia, anterior tibial, peroneal
Vascular Update 2011
BYPASS SURGERY
• Reverse vein graft
• Better patency
• Less complication
• Natural conduit
• Less severe symptoms if thrombosed
• Limited
• Prosthetic graft (PTFE)
• Comparable patency for proximal lesions
• Complication
• Graft infection
• Severe symptoms if occluded
Vascular Update 2011
LOCAL WOUND TREATMENT
• Debridement / desloughing
• Wound care and dressing
• Minor amputation
• Eliminate necrotic tissue
• Reduce septic focus
• Promote granulation tissue
Vascular Update 2011
AMPUTATION
• Primary amputation
• Consider in selected cases
• Non-salvageable foot
• Poor revascularisation outcome
• Poor distal run-off
• Severe generalised, calcified vessel
• Patient selection
• Poor cardiac function
• Poor pre-morbid condition
• Not a failure of treatment
• Aim – to regain mobility Vascular Update 2011
REHABILITATION & FOLLOW-UP
• Rehabilitation
• Mobilisation
• Prosthesis
• Foot wear
• Follow-up
• Control of risk factors
• Continuation of medications
• Surveillance
• Recurrent stenosis
• Failing bypass grafts
Vascular Update 2011
TAKE HOME MESSAGE
CHRONIC LIMB ISCHAEMIA:
• Early diagnosis
• Examine pulses
• Early referral
• Life before limb
Vascular Update 2011
THANK YOU
www.hklvascular.com
