Mr B, a 65-year-old man, presented with a blackened left big toe and cyanosis of the left foot for 8 months. Examination found absent pulses in the left foot with ulceration and gangrene. He has risk factors including hypertension, diabetes, smoking and sedentary lifestyle. Critical limb ischemia was diagnosed based on clinical features and absent pulses, threatening the viability of his left leg. Treatment goals are to relieve pain, prevent amputation, and improve quality of life through risk factor control, revascularization procedures if possible, or amputation as a last resort.
2. Mr B
65 years old
Painful black left toe
Pain and bluish discoloration of the left foot for the past 8 months
- Worsened in the past 3 weeks
- Disturbed his sleep
No numbness or paraesthesia
Did not recall any trauma to his left foot or toe.
U/L
Hypertension and type 2 diabetes mellitus
.
LET’S START WITH A CASE STUDY..
3. Mr B is a retired restaurant owner and a smoker.
He has regularly drunk 1–2 glasses of white wine a day for the past 50 years.
His father and two of his brothers died of heart attacks.
Mr B has led a sedentary life for the past 4 decades, with minimal sports activity.
On examination :
- 2 x 2 cm black eschar on the plantar aspect of the left big toe
- well demarcated margin of granulation tissue
- the eschar was not tender to palpation
- cyanosis over the second and third toe extending to the dorsum of the left foot.
- foot felt cold to palpation
- absent dorsalis pedis and posterior tibial pulses.
- right foot was normal in comparison
- ould not weight bear on his left foot and limped due to poor balance.
4. LET’S THINK!
What is the diagnosis
01.
How to assess the
severity
03.
What are the risk
factors for Mr B
02.
What are the goal of
treatment
04.
5. 1. Gangrene of the great toe due to critical limb ischaemia (CLI).
2. Sedentary lifestyles, U/L diseases, strong family history, smoker
3. The Ankle Brachial Index (ABI) is considered the first line investigation for diagnosing
peripheral arterial disease of the lower limb. Critical limb ischaemia is defined as having an
ABI of 0.4 or less. To further locate the levels of stenosis and assess their severity,
noninvasive imaging techniques like computed tomography angiography and magnetic
resonance angiography can be considered before the more invasive gold standard
investigation of digital subtraction angiography. Peripheral arterial diseases can be
classified into Fontaine stage I to IV,5 or Rutherford category 0 to 66 according to clinical
symptoms and evidence of tissue damage.
4. Goals of treatment for CLI include pain relief, management of ulcers and infections,
improvement of quality of life, revascularisation without amputation and longer overall
survival. Current consensus is to avoid limb amputation if possible, and when necessary, a
below knee approach is preferred for better ambulation and lesser mortality (5% mortality
for below knee amputation vs 16% for above knee amputation
6. DEFINITION
❖ Decrease in limb perfusion in major artery of lower limb which
causes potential threat to limb viability, in combination with
rest pain, gangrene, or a lower limb ulceration >2 weeks
duration
❖ Most common cause is atherosclerosis causing diffuse stenosis
of peripheral arteries causing diminished blood supply to lower
limb- supply demand imbalance
9. EPIDEMIOLOGY
❖ Affects >200 million people worldwide
❖ Prevalence increases with population age
❖ Prevalence in general population varies from 2% to 18% between ages 40 to 80
❖ Higher in male population
❖ Prevalence higher in diabetic populations: 10 to 42%
❖ Untreated, 50% of patients will proceed to limb amputation and 25% will die within 1
year
10. RISK FACTORS
DIABETES MELLITUS HYPERTENSION HYPERLIPIDAEMIA
SMOKING FAMILY HISTORY OBESITY AND
SEDENTARY
LIFESTYLE
INCREASING AGE
11. CLINICAL FEATURES
❖ Intermittent claudication
A cramping-type pain in the calf, thigh, or buttock after walking a fixed distance (the ‘claudication
distance’). Relieved by rest within minutes
❖ Ischemic rest pain
Burning pain in the ball of the foot and toes that is worse at night when the patient is in bed.
The pain is exacerbated by the recumbent position because of the loss of gravity-assisted flow to the
foot. Relieved by dangling the legs over the side of the bed
❖ Non healing wounds / ulcers
❖ Gangrene (tissue necrosis)
❖ Absent/ diminished pulses- Femoral/Popliteal/ PTA/ DPA
❖ Trophic changes
↓ Skin temperature ↓ Perspiration ↓Hair on legs Brittle nails Atrophic, shiny skin
12.
13. HISTORY
❖ To enquire the risk factors
❖ History of cardiac disease
❖ Intermittent claudication- Site, nature, alleviating and aggravating factors, duration,
neurogenic vs vascular
❖ Ischemic rest pain- relieve with analgesics/ requiring opiods?
❖ Ulcer- onset, progress, foot care
❖ Gangrene- associated with systemic signs of infection?
14. PHYSICAL EXAMINATION
❖ Inspection:
Attitude of limb (hanging down over the bed?)
Muscle wasting
Skin - gangrene : blackish, dry/ wet, extent of gangrene
Signs of chronic ischemia - loss of hair, loss of subcutaneous fat, atrophic unhealthy skin,
trophic changes (loss of hair, dry and shiny skin, nail changes)
❖ Palpation: temperature (cold), gangrene area (sensation, tenderness, movement), CRT,
pulses, motor and sensation
15. SPECIAL TESTS
In normal individuals pallor do not
develop even at 90’. If Buerger
angle <30’, indicates limb ischemia
18. ABPI
❖ Calculated by systolic blood pressure
in ankle by systolic blood pressure in
arm
❖ Quantify severity of chronic limb
ischemia
❖ All claudication patient should have
resting ankle systolic pressure
measuring in clinic
❖ Normal value 0.9-1.2
19. DOPPLER ULTRASOUND
❖ Used to :
- Assess patency of the arteries, allowing detection of
decreased blood flow
- Assess the severity and anatomical location of any
occlusion
20. ARTERIOGRAPHY
❖ Arteriography is performed by injecting a
radiopaque contrast material into the
artery and then observing blood flow
through the arterial system with x-ray.
❖ Reserved for patient thought to require
angioplasty or reconstructive surgery
❖ Showing sites and severity stenosis and
occlusion
❖ Risks of bleeding from arterial puncture,
damage to artery with worsening
ischemia, contrast allergy
24. SURGICAL INTERVENTION
Indication: threatened limb, failed conservative management, poor quality of life
❖ Revascularization: either percutaneous transluminal angioplasty (PTA) with or without stenting,
or bypass graft
PTA: Revascularization procedure in which catheter with balloon at its tip is passed to the site of
arterial occlusion-balloon is inflated to relieve obstruction
-Only effective for focal stenotic lesions- however, restenosis can occur
-Preferred for patients not fit for bypass
Bypass grafting- when lesions cannot be treated by angioplasty: eg lesion extends long distance
through the vessel/ complete occlusion
25. ❖ Amputation: Last resort- necrotic tissue, gangrenous, ascending sepsis
-Level of amputation depends of vascularity of the limb- as far as possible to prevent function of
the lower limb
-Ensure good vascular supply to surgical site otherwise poor wound healing
Notas do Editor
*Critical Limb Ischemia was renamed Chronic Limb-Threatening Ischemia (CLTI) in 2019. The name CLTI better reflects the broad range of patients with reduced blood flow that can delay wound healing and increase amputation risk
Latest guideline by European Society for Vascular Surgery and Cardiology
Intermittent claudication - one of the earlier symptoms
Amputation: Last resort- necrotic tissue, gangrenous, ascending sepsis
-Level of amputation depends of vascularity of the limb- as far as possible to prevent function of the lower limb
-Ensure good vascular supply to surgical site otherwise poor wound healing
In normal individuals pallor do not develop even at 90’. If Buerger angle <30’, indicates limb ischemia
