Lecture on chronic limb ischaemia for medical students. Encompasses basic sciences, classifications and principles of management.

1. Chronic limb ischaemia
Chea Chan Hooi
Surgeon
Sibu Hospital

2. • Introduction
• Definition
• Risk factors
• Clinical features
• Classification
• Investigations
• Treatment options

3. Introduction
• AKA arteriosclerosis obliterans, peripheral
vascular disease, peripheral arterial disease
• Asymptomatic  critical ischaemia
• LL>UL
• Epidemiology is difficult to ascertain due to
wide spectrum of symptoms & poor reporting

4. Definition
• Chronic limb ischaemia
– Inadequate perfusion of limbs
– >2 weeks
• Intermittent claudication
– Muscular pain, classically in the calves
– During exercise
– Relieved by rest and similarly reproducible when
the exercise is resumed

5. • Critical limb ischaemia
– Rest pain: Persistent recurring ischaemic pain
during rest >2 weeks, requiring analgesics
– Tissue loss: Limb ulcer, gangrene or non-healing
wound
– Ankle systolic pressure ≤50mmHg or toe
≤30mmHg

6. Risk factors
Modifiable
• Smoking
• Metabolic syndrome
• Hypertension
Non-modifiable
• Male
• Aging

7. History
• Presentation
– Asymptomatic
– Intermittent claudication
– Critical limb ischaemia
– Chronic limb ischaemia
• Risk factors
• Differential diagnoses
• Compliance to medications
• Previous intervention(s)
• Significant comorbidities – including other arterio-occlusive
conditions
• Ambulatory, quality of life

9. Physical examination

10. WHERE?

11. WHY?

12. HOW?

15. • Other relevant examiations
– Carotid bruit
– Cardiac murmur
– Bibasal lung creps
– AAA
– Complete CNS examination

16. Investigations
• Toe plethysmography
– Distal perfusion
– Especially diabetic patients
• Imaging options
– Duplex ultrasound
– CT angiography
– MR angiography
– Conventional angiography
– Digital subtraction angiography

20. Treatment
• Multidisciplinary team effort
– Physician
– Dietician
– Physiotherapist
– Occupational therapist
– Interventional radiologist
– Vascular surgeon
– Orthopaedic surgeon
– Plastic surgeon

21. • Intermittent claudication
– Lifestyle modification
• Stop smoking
• Exercise program
– Best medical therapy
• Tight glycaemic and blood pressure control
• Lipid-lowering agents
• Anti-platelets
– Analgesics

22. • Definitive intervention
– Indicated
• Debilitating claudication refractory to non-surgical
therapy
• Critical limb ischaemia

23. • Endovascular
– Short lesion(s)
– Vessels proximal to the knee
– Elderly patient with multiple comorbidities & expected
lifespan <2 years3
• Open by-pass surgery
– Long segment lesions
– Lesion at origin of vessels
– Expected lifespan >2 years
• Hybrid approach
– Decision made on MDT discussion based on a case-to-case
basis

25. • Amputation
– Patient
• Dementia
• Dependent activity of daily living
• Non-ambulatory
• Limited life expectancy
• Terminal illness
– Disease
• Unreconstructable lesion(s)
• Significant weight-bearing necrosis

26. • Rehabilitation
• Follow-up

27. TQ!
Q&A?