Chronic limb ischemia

1. Approach to patient with chronic
limb ischemia
Mohammed AlHinai

2. • Here, I will discuss the approach to patient with chronic limb ischemia. For more detail
about the disease :
https://drive.google.com/open?id=1rXTFDFl3sBEE2Bf59iU5_1jDbP0EdXbP

3. • A 60 years old man known case of DM type 2 and dyslipidemia, has been referred to
surgical outpatient clinic with one year complaint of both leg pain. His pain has
worsened gradually. He is unable to walk without pain. As well he has developed ulcers
over his right sided 4th and 5th toes. Clinically, he is in pain. Both legs showed signs of
inadequate blood supply. There is no palpable abdominal mass; there is a palpable
thrill over his left femoral pulse which is felt with difficulty. His distal pulses are absent.
Differential diagnosis
Most common cause
of chronic limb
ischemia

4.  Take full history about clinical manifestation.
 Do physical examination which are :
• General examination.
• Examination of lower limb include inspection for blood inadequate signs and presence
of ulcer or gangrene. Then, Palpation of pulse, temperature and tenderness.
• Do wave doppler for presence of pulse.
• Do ABPI
• Do neurological examination for lower limb.
• Complete your examination with other systems include cardiac and respiratory
examination.
ABPI Wave doppler

6. From history and
examination, you need
to get two things
Site of occlusion clinically Severity of clinical manifestation
according to Fontaine
classification

7. without pain on resting, but with claudication at
a distance of greater than 650 feet (200 meters)
without pain on resting, but with a claudication
distance of less than 650 feet (200 meters)
Nocturnal and/or resting pain
Necrosis (death of tissue) and/or
gangrene in the limb
In case presence of rest pain for more than 2 weeks with ulceration or gangrene or ABPI
less than 0.3, indicate that the patient has critical limb ischemia which is most severe and
require immediate intervention.

8.  Laboratory studies :
• No specific biomarkers for ischemic limbs but other tests required as baseline for
patient as well for other following procedures as surgical intervention. These tests
include:
- CBC, coagulation profile, RFT, LFT, lipid profile, blood sugar, ECG.
• Plain Xray of lower extremity (not necessary done) may show arterial calcification.
• Exercise testing done for those who have classic history of claudication and others
with atypical extremity pain and having normal resting ABPI.

9.  US imaging of lower limb :
• used to evaluate the location and extent of vascular disease, arterial hemodynamics,
and lesion morphology
Two US modes are routinely
used in vascular imaging
B (brightness) mode :
• Used to identify the location of
diseased artery and identify the
diameter of artery if stenosis or
occlusion or dilated in aneurysm.
Duplex US (mixed of B mode and
Doppler flow) :
• More accurate than B mode
• Same result of B mode with
identify the velocity of blood flow
at site of diseased artery.

10. B mode US
B mode
Doppler
flow
Duplex US
Two things need to comment
when apply duplex US
Morphology of waves :
• Tri-phasic (normal).
• Bi-phasic (moderate stenosis)
• Mono-phasic (severe stenosis)
Peak systolic velocity :
• Normal velocity depend on artery.
• More stenosis lead to increase the
velocity.
• If severe stenosis and obstruct the
artery, will lead to decrease the
velocity until 0 cm/s

11. Morphology of waves

12.  Advanced imaging include angiography :
• Important for confirm the diagnosis and for planning an intervention.
• CT angiography (CTA) :
- initial study for advanced vascular imaging.
- Abnormal result shown as filling defect in affected artery.
• MR angiography (MRA) :
- Done if CTA contraindication in case of renal failure or contrast allergy.
• Conventional arteriography :
- involves the intravascular injection of a contrast agent during planar radiographic
imaging and act as dynamic study.
- also offering the option for simultaneous intervention but has more side effect includng
arterial puncture, higher doses of ionizing radiation compared with other imaging
methods, and potential for nephrotoxicity.
Conventional arteriography CTA MRA

13. Treatment
Depend on distribution of disease, the length and severity of any arterial
stenoses or occlusions by anatomic location, and the length of diseased
segments which determinate by advanced imaging
 Any patient diagnosed with peripheral artery disease, should be on medical therapy
(best medical therapy) :
 Criteria for intervention :
• The patient is significantly disabled by claudication.
• Severity of disease involve stage IIb, III and IV on fontaine classification.
• No improvement of medical therapy on mild claudication.
To choice the type of intervention, apply TASC II
which reflect the location and extent of affected
segment

14. TASC II classification of aortoiliac lesion

15. TASC II classification of femoropopliteal lesions

16. Choice of initial interventionTASC II classification of aortoiliac or
femoropopliteal lesions
Endovascular treatment including ballon
angioplasty +/- stenting
TASC type A
Endovascular treatment preferred over
surgical treatment but if failed, may also
benefit from surgery.
TASC type B
Patient who are not good-risk
candidates for surgery may also benefit
from percutaneous intervention, but for
good-risk candidates, surgery is
preferred including bypass graft.
TASC type C
Surgery is the treatment of choiceTASC type D