CRITICAL LIMB ISCHEMIA

Definition and Workup

Presented by; Sultan Al Sheikh

Definition
Inadequate arterial blood flow to accommodate the metabolic needs of resting tissue Two important variables: clinical symptoms measured circulatory impairment

Definition
TASC definition: persistent , recurring ischemic rest pain requiring opiate analgesia for at least 2 wk ulceration or gangrene of the foot or toes, and ankle systolic pressure less than 50 mmHg or toe systolic pressure less than 30 mmHg ( or absent pedal pulses in patients with DM)

CLI
Mortality rate : claudication is 50% at 5y CLI 70% at 7y and 85% at 10y

classification
Traditional Fontaine classification system: I Asymptomatic II Claudication III Ischemic rest pain IV Ischemic ulceration/necrosis

CLI
Fontaine stage III & IV: rest pain pedal necrosis : ischemic ulceration or necrosis Documentation of circulatory impairment

CLI
Circulatory impairment ( TASC ) :
ankle pressure less than 50 to 70 mmHg Toe pressure less than 30 to 50 mmHg Transcutaneuos partial pressure of

oxygen at the foot is less than 30 to 50 mmHg

CLI
CLI can progresses directly from fontaine I to stage III & IV Dormandy ( multicenteric) : 50% were asymptomatic 6 m before major amputation for CLI In general CLI inevitably progress to limb loss without revascularisation

CLI
At least 2 or more levels of severe arterial occlusion. Usually fempop or infrapop occlusion ( adjacent vascular bed ) or superficial femoral and deep fem (parallel beds)

ATHEROSCLEROSIS
Age Male gender DM Smoking hypertention Hyperlipidemia Hyperfibrinogenemia Hyperhomocysteinemia hypercoagulability

Rest Pain
Definition Age Sex Symptoms H/O claudication Previos History Family History

Rest Pain
General appearance Local exam: horizontal------- pale,guttered veins dependent------deep reddish-purple pressure areas temp. capillary refilling. Pulses auscultation

Gangrene
Dead tissue Line of demarcation Infected ( wet gangrene) Non-infected ( dry gangrene )

Ulceration
Causes: large-artery obliteration: atherosclerosis , embolism. small-artery obliteration: raynauds diseas, scleroderma, Buergers disease, embolism, radiation, electric burn.

Ulceration
Position Tenderness Temperature Size Edges Base Depth Discharge Relations:bare bone or tendon at the base

Cardiac and cerebrovascular evaluation

Systemic nature of atherosclerosis must be assessed in all pt with new onset PAD Duplex for carotids ( 28% significant stenosis in pt with infrainguinal bypass)

Clinical predictors of increased CV risk: MI,HF,death

MAJOR Unstble coronary syndrome Decompensated HF Significant arrhythmias Severe valvular disease

Intermediate Mild angina Previous MI Compensated HF DM Renal insufficiecy

Clinical predictors of increased CV risk: MI,HF,death

Minor Advanced age Abnormal ECG (LT vent. Hypertrophy, LBBB) Rhythm other than sinus Low functional capacity H/O stroke Uncontrolled HTN

Evaluation
Surgical or percutaneous intervention: symptoms co-morbidity location severity

Evaluation
Segmental arterial pressure and ABI presence location supranormal ABI correlate with pulse volume recording and toe pressure little benefit in planning intervention

Exercise test
In pt palpable pulses but disabling symptoms ankle pressure at rest treadmill at 3.5 km/h measure again

Duplex imaging
Non invasive , low cost , operator dependent Delineate arterial anatomy and blood flow Aly and colleage ( 90 pts) sens. 92% and spec. 99% for occlusion sens 89% and spec 98% for lesion length

Contrast intra arterial subtraction angio

Most commonly used for planning intervention Complete visualzation Risks: reaction 0.1% mortality 0.16%

Complications of angiography
Puncture site hemorrhage/hematoma pseudoaneeurysm arteriovenous fistula atherembolization local thrombosis

Complications of angiography
Contrast related major sensitivity reaction ( anaphylactoid) minor reaction vasodilation / hypotesion nephrotoxicity hypervolemia ( osmotic )

MRI
Gadolinium enhanced Entire arterial tree , including pedal vessels Superior for patent distal vessels Difficulties: metallic implants claustrophobia gadolinium More cost effective ( in considering angioplasty) Angiograph superior for planning surgery

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