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EBM Guidelines
20.3.2017
Essentials
Signs and symptoms of chronic ischaemia
Conservative treatment of intermittent claudication
Surgical management of chronic ischaemia with intermittent claudication
Critical ischaemia
Symptoms and diagnosis of acute ischaemia
Surgical treatment of acute and critical ischaemia
Related resources
References
Essentials
Acute lower limb ischaemia is in most cases caused by sudden obstruction of an artery
due to an embolus or thrombosis. Rare causes that should be kept in mind include aortic
dissection and thrombosis of a popliteal aneurysm.
Chronic lower limb ischaemia is a slowly progressing disease process that is usually
caused by an obliterating arterial disease.
Acute lower limb ischaemia must be recognized and the patient immediately referred for
further management.
Chronic lower limb ischaemia must be diagnosed and its severity (stage) assessed, as the
severity of the condition will determine management approach.
o Mild ischaemia is asymptomatic, but is suggestive of an increased overall
cardiovascular risk.
o Moderate ischaemia causes intermittent claudication which, as such, is a benign but
troublesome complaint. Claudication may be treated conservatively, but if the
condition threatens the work or functional capacity of the patient, a referral to a
vascular surgeon is indicated.
o Critical ischaemia manifests itself as pain at rest and may lead to a non-healing
chronic leg ulcer and eventually to gangrene. Patients with critical limb ischaemia
require urgent referral to a vascular surgeon. If limb ischaemia is complicated by an
infection or if a gangrene has developed fast, an emergency referral is indicated.
If ischaemia is suspected it should be verified by measuring the ankle and brachial
pressures with Doppler ultrasonography in all suspected cases of ischaemia. Examination
of the patient, see 1.
A patient suffering from lower extremity ischaemia always has atherosclerosis also
elsewhere than in the arteries of the lower extremities (ASO). Consequently, the
prevention of coronary heart disease and ischaemic cerebrovascular disorders should be
taken care of by controlling the risk factors (hypertension, dyslipidaemia, smoking,
diabetes). This has the greatest impact on the patient’s prognosis.
Critical ischaemia
The term critical ischaemia is used to denote the worsening of chronic ischaemia leading
to the threat of gangrene in the lower extremity. Symptoms include rest pain and/or
gangrene or an incurable ulcer in the foot area.
Should be suspected if a leg ulcer shows no signs of improvement in two weeks. A typical
sign of ischaemia is distal gangrene ("toe infarct") as well as an ulcer outside the usual
pressure areas, which are the heel and ball of the foot. An ulcer must not be treated
blindly, and the cause of the problem should be established.
The limb will feel cool or cold to touch and have abnormal colouring.
50% of patients with critical ischaemia have diabetes.
The patient may perceive the ischaemia as numbness.
Concomitant deep venous insufficiency and a venous ulcer may make the diagnosis
difficult. It should be kept in mind that in the background there may be insufficiency of
both arterial and venous circulation, and ABI should be measured in a patient with a leg
ulcer as well.
Ischaemia should be considered critical if
o the patient has severe pain during the night, when at rest
o the patient has foot gangrene or a foot ulcer that does not improve, and the ankle
brachial index (ABI) is < 0.85. In a patient with diabetes, the reading taken with a
Doppler stethoscope may be falsely high, but the presence of ischaemia will be
revealed by a faint, monophasic flow signal.
Critical ischaemia requires urgent by-pass surgery or extensive endovascular
recanalisation in order to avoid amputation (above or below knee).
If critical ischaemia is suspected, the patient should be referred without delay, even as an
emergency case, to a vascular surgery unit where all potentially mobile patients will
either undergo angiography or immediate vascular reconstruction.
Critical ischaemia is often associated with long occlusions in the thigh and leg arteries.
The patients are often elderly and have multiple co-existing illnesses and poor life
expectancy. However, an attempt should be made to salvage the limb even in elderly
patients if the choice is between independent living and amputation followed by
institutional care.
Primary amputation is carried out in patients in poor general health who no longer are
able to mobilise independently and in cases where the gangrenous tissue covers at least
half of the foot.
A patient who has undergone amputation due to ischaemia is not likely to learn to walk
with a prosthesis, and reconstructive vascular surgery should therefore be the
management of choice whenever possible.
Related resources
1. Cochrane reviews 1
2. Other evidence summaries 1
3. Clinical guidelines 1
4. Literature 1
References
1. Girolami B, Bernardi E, Prins MH, Ten Cate JW, Hettiarachchi R, Prandoni P, Girolami A, Büller HR. Treatment
of intermittent claudication with physical training, smoking cessation, pentoxifylline, or nafronyl: a meta-
analysis. Arch Intern Med 1999 Feb 22;159(4):337-45. PubMed
2. Vuorisalo S, Venermo M, Lepäntalo M. Treatment of diabetic foot ulcers. J Cardiovasc Surg (Torino)
2009;50(3):275-91. PubMed
3. European Stroke Organisation., Tendera M, Aboyans V et al. ESC Guidelines on the diagnosis and treatment
of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and
vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and
Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J
2011;32(22):2851-906. PubMed
Authors:
Maarit Venermo
Previous authors:
Mauri Lepäntalo
Article ID: ebm00101 (005.060)
© 2017 Duodecim Medical Publications Ltd