chronic lower limb ischemia

1. Dr. SamehAttiaAli AbdelhamidDr. SamehAttiaAli Abdelhamid
MBBChMBBCh, MSc, MSc
EgyptianBoardof VascularEgyptianBoardof Vascular
SurgerySurgery
MRCSMRCS

2. Definition:
o The decrease in arterial blood supply to the
tissues due to partial or complete occlusion of
arteries.
o The severity of symptoms is related to the size
of the vessel occluded & alternative routes
(collaterals) available for blood flow.

3. Causes:
Atherosclerosis
Burger’s disease
Raynaud’s disease
Others

5. • The blood flow is restricted by a gradual
narrowing of the arterial lumen.
• During exercise the blood supply to the
tissues is not adequate for increasing energy
demands.
• The products of anaerobic metabolism (lactic
acid and potassium) accumulate and cause
pain.

6. ◦ Smoking
◦ Hypertension
◦ Hyperlipidaemia (raised LDL) High risk
◦ High fat diets factors
◦ Diabetes mellitus
◦ Renal disease Other risk
◦ Familial history of premature atherosclerosis factors
◦ Male sex
◦ age
◦
◦
◦ Sedentary life
◦ Obesity Factors having an
uncertain
◦ Anxiety role

8. • Asymptomatic disease.
• Intermittent claudication.
• Critical limb ischemia.

9. ~15%
Claudication
~33%
Atypical
Leg Pain
(functionally limited)
50%
Asymptomatic
1%-2%
Critical
Limb Ischemia

10. Symptoms:
classically occurs in elderly male patients.
 Cigarette smokers.
may have other manifestations of atherosclerosis

11. • Muscular atrophy.
• Decrease hair growth.
• Thick toenails.
• cool skin .
• poor healing.
• Tissue necrosis ulcers infection .
• Absent pulses.
• Bruits.

12. Inspection
 Color
 Posture of the limb.
 Venous guttering.
 Gangrene.
 Ulceration.
Palpation
 Temperature.
 Capillary refilling.
 Pulses.
 Sensation and movement.
Auscultation
 Bruit.

16. • Normal >0.97 (usually 1)
• Claudication 0.50-0.70
• Rest pain 0.30-0.50
• Ulceration and gangrene 0.10-0.30

18. • Pain or discomfort in the calf or buttocks produced by
walking and relived by rest.
• The pain steadily increases until the patient is
compelled to stop.

19. • Resting in the upright position rapidly relieves the
pain within a few minutes.
(claudication distance)
• Resumption of walking will reproduce the pain at
exactly the same distance as before .

20. (Leriche's syndrome)
• Aortic occlusion which produces buttock pain and loss of
erection in the male

21. • Majority will have Symptomatic stabilization ??
• Development of collaterals.
• Metabolic adaptation of ischemic muscle.
• The patient altering his life.
• 25% will deteriorate
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22. The treatment goals are to
• relieve symptoms.
• improve exercise performance and daily
functional abilities.

23. 23

24. 24

25. • Failure to respond to exercise and /or drug
therapy.

27. is a manifestation of peripheral arterial disease
(PAD) that describes patients with
• ischemic rest pain
• ischemic ulcers
• gangrene.
• chronic ischemia is defined as the presence of
symptoms for more than 2 weeks.
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28. 28

29. • characterized by:
• continuous aching severe pain.
• usually in the most distal part of the limb.
• worse at night in bed.
• the patient seeks relief by hanging the leg over the side of the
bed or sleeping in a chair.
• often associated with tissue loss (ulceration or gangrene).

30. • Patients with CLI may also the first
presentation is ischemic ulcers or gangrene
as In patients with diabetic neuropathy.
• Gangrene usually affects the digits.
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33. • most commonly occurs below an ankle pressure of 50
mmHg or a toe pressure less than 30 mmHg.

34. • non-disabling claudication
• disabling claudication
• critical ischemia.

35. Laboratory :
• Blood sugar.
• Lipid profile
• CBC ,Hb
• Plasma fibrinogen
• urine glucose
ECG

36. non-invasive
• Doppler ultrasound
• ABI ( rest and exercise )
• Segmental pressure measurement
• Duplex imaging
invasive
• CTA
• MRA
• Angio

37. Exercise test:
• Helps to establish the diagnosis of
PAD.
• A decreased in ABI of 15-20%
after exercise would be diagnostic
of PAD if the resting ABI is
normal.

38. • calculated by dividing the toe pressure by the higher of the two
brachial pressures.
• accurate when ABI values are not possible due to non-
compressible pedal pulses.
• TBI values ≤ 0.7 are usually considered diagnostic for lower
extremity PAD.

40. • Effective method of predicting the location and
severity of arterial disease in the lower
extremities
• Can distinguish between stenoses and
occlusions.
• ideal for predicting access sites for intervention,
and can detect iatrogenic arterial injury after
intervention.

43. • Requires iodinated contrast
• Requires ionizing radiation

44. • No ionizing radiation
• Noniodine–based intravenous contrast medium
rarely causes renal insufficiency or allergic
reaction
• Gadolinium use may cause nephrogenic
systemic fibrosis (NSF)

46. • Smoking.
• Obesity .
• hyperlipidemia .
• hypertension.
• diabetes.
• co-existing disease.

47. • Smoking cessation
• smoking cessation is associated with improved walking
distance in some patients.
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48. • Weight reduction
Patients who are
• overweight (BMI 25-30)
• or obese (BMI >30)
should receive counseling for weight reduction by
inducing carbohydrate restriction and increased
exercise.
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49. • Hyperlipidemia is Independent risk factors for PAD
which include elevated levels of
• Total cholesterol
• Total low-density lipoprotein (LDL)
• Total triglycerides
• Factors that are protective for the development of
PAD are elevated high-density lipoprotein (HDL)
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50. • Hypertention associated with a 2-3 fold
increased risk for PAD.
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51. • Diabetes increases the risk of PAD
approximately
3-4 fold.
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52. Treatment
The primary goals of the treatment are to
◦ Relieve ischemic pain.
◦ Heal ischemic ulcers
◦ Prevent limb loss
◦ Improve patient function and quality of life.
◦ Prolong survival.
In order to achieve these goals, most patients will
ultimately need a revascularization procedure.
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53. • Treatment
• Aggressive modification of their cardiovascular risk factors.
• Pharmacotherapy.
• Revascularization.
• most patients with CLI will ultimately need a revascularization
procedure.
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