A complete seminar on chronic lower limb ischemia

1. Dr Minhajuddin Khurram
Al-Ameen Medical College
Bijapur (Karnataka)
India

2. Peripheral areterial occlusive disease
(PAOD/PAD/PVD) refers to the obstruction or
detoriation of ateries other than those supplying
the heart and within the brain

3.  Impairment of circulation
 Incidence increases with age
 0.3%/yr (40 to 55yrs) to 1%/yr (after 75yrs)
 Quality of life/cost of treatment
 Non whites> whites
 Male gender
 Obesity

4.  Black (hispanic)
 Increasing age
 Smoking
 Hypertension
 Dyslipidemia
 Hypercoaguble states
 Renal insufficiency
 DM
 Younger>aged

5.  Family history of vascular disease or stroke/
heart attack
 In study
 C-reactive protein
 Homocysteine

7.  Intima
 Internal elastic membrane
 Media
 Composed of smooth m/s, collagen, elastin and
preteoglycans
 Blood suply:
 Internal half: Direct diffusion
 External half: vasa vasorum
 External elastic membrane
 Adventitia
• Fibroblasts and collagen

9.  Acute
 Sudden occlusion of an artery
 No time for collateral openings
 Poikilothermia, Pain, Pulseless, Pallor, Parasthesia
and Paralysis
 Chronic
 No sudden obstruction
 Gradual narrowing of lumen
 Enough time for collaterals to develop
 More tolerant to prolonged ischemia

10.  Atherosclerosis {lower limb}
 TAO (Buerger’s Disease) {lower limb}
 Infective
 Vasculitis syndromes

12.  Atherosclerosis =
Athero + sclerois
 Plaque composed of
smooth m/s, lipids,
connective tissue and
macrophages

13.  Brief pathophysiology
 Lipid deposition calcification erosive
areas and ulceration prothrombotic cell
activity plaque lipid core becomes necrotic
covered by FIBROUS CAP rupture,
perceived as injury laying down of platelets
and formation of a clot.

15.  Ischemia may be due to
 Narrowing of the lumen
 Rupture leading to fibrous cap
 Embolization

16.  More shearing stress/
increased turbulence
 Infra renal aorta
 Iliac bifurcation
 Carotid bifircation
 Superficaial femoral
arteries
 Ostia or renal, coronary
and mesenteric arteries.

17.  Inflammatory reaction of the arterial wall with
involvement of neighboring vein and nerves
 2nd to 4th decade of life; male>females
 Specifically linked to smoking
 Low socio-economic groups
 Recently, familial disposition and autoimmune
mechanism has also been postulated

19.  Pathology
smoking (nicotine)
Increased % carboxy hb
vasospasm damage to the vessel wall
TAO fibrosis

20.  Involves medium and small sized vessels;
those distal to the popliteal artery
 Very rare upper limb involvement
 Acute Lesion:
 Arteritis, periarteritis, acute phlebitis (migratory in
30%) and periphlebitis.
 Invasion of wall by polymorphs and giant cells.
 Thrombus, with microabscesses

21.  Chronic Lesion
 Arteries and veins bound together by fibrosis
 Nerve involvement
 Fibroblastic activity and endothelial proliferation in
the thrombus
 Thrombus organized as fibrous tissue

22.  Pain (Intermittent claudication)
 “Claudio”= I limp
 Cramp like pain
 Brought on by exercise
 Not present on walking the first step
 Relieved by standing still
 Slight variation each day
 Due to accumulation of substance P
 Site of Claudication:
 Group of muscles distal to the site of obstruction

23.  Pain (Intermittent claudication)
 Clinical Classification
a) Boyd’s Classification
Grade Pain
I Pain relieved on continued walking
II Walks in pain
III Compelled to take rest
IV Pain at rest

24.  Claudication distance : distance at which the
pain first appears

25. b) Fontaine Classification

26. c) Rutherford Classification

27.  Pain (Intermittent claudication)
 Occlusion and site of claudication
Site of Occlusion Claudication site/ other symptoms
Aorto-iliac
obstruction
• Claudication in in both buttocks, thighs and calf
• Absent femoral, popliteal and DP pulses
• Impotence (Leriche’s syndrome)
Iliac obstruction • Unilateral claudication in thigh and calf
• Unilateral absence of femoral and distal pulses
Femoropopliteal
obstruction
• Unilateral claudication in the calf
• Absent distal pulses
Distal obstruction • Ankle pulses absent
• Claudication in calf and foot

28.  Pain (Intermittent claudication)
 Rest pain
 Grade IV Boyd’s classification
 Felt in the foot (most distal parts)
 Due to ischemia of the somatic nerves (cry of the dying nerves)
 Exacerbate on lying down or elevation of foot
 Worse at night; patient sits in “hen-holding” position
 Pressure of even bed clothes worsens the pain
 Lessened by hanging the foot down or sleeping on a chair
 Patient may commit suicide

29.  Pain (Intermittent claudication)
 Rest pain – “Hen-holding”

30.  Pain (Intermittent claudication)
 Critical limb ischemia
 Persistently recurring ischemic rest pain requiring
regular, adequate analgesia for more than 2 weeks or
ulceration or gangrene of foot or toes with ankle
pressure <50mmHg or toe pressure <30mmHg

31.  Pain (Intermittent claudication)
 Differential Diagnosis
1. Nerve root compression (eg: herniated disc)
Sharp lacinating pain
Sudden onset on walking
History of back problems
2. Spinal stenosis
History of back problems
Motor weakness more prominent
Onset by standing also
Relived by change in position

32.  Pain (Intermittent claudication)
 Differential Diagnosis
3. Arthritic/ inflammatory
Aching pain
Variable pain
Not relieved as quickly
4. Baker’s cyst
Swelling, tenderness
Rest pain
Subsides slowly
Not intermittent

33.  Pain (Intermittent claudication)
 Differential Diagnosis
5. Venous claudication
Bursting type of pain
Relief speeded by elevation
h/o DVT
Signs of venous congestion
6. Chronic compartment syndrome
Bursting pain
Heavily muscled legs
Relief speeded by elevation

34.  Other symptoms
 Ulceration
 Gangrene
 Loss of senstion
 Loss of movements

35.  History
 Can identify the location and severity of the disease
 Pain:
 Location
 Precipitating and aggravating factors
 Frequency, duration and evolution
 Rule out other causes of pain in the lower limbs
 Patients with co- morbid conditions who cannot walk present
late with gangrene and rest pain
 Drug/Medical history
 Surgical history
 Family history : first degree with abdominal aortic aneurysm

36.  History
 Vascular review of symptoms
 TIA
 Difficulty in speech or swallowing
 Dizziness/ drop attacks
 Blurry vision
 Arm fatigue
 Pain in abdomen after eating
 Renal insufficiency (poorly controlled hypertension)
 Impotence
 Claudication
 Rest pain or tissue loss

37.  Physical examination
 Inspection
 Change in colour
 Signs of ischemia
 Bueger’s test
 Capillary filling test
 Venous refilling
 Pregangrenous/ gangrenous part examination

38.  Physical examination
 Palpation
 Skin temperature
 Venous refilling
 Perpheral pulses
 Disapperaing pulse
 Joint movements / muscle strength
 Sensations
 Auscultation:
 Bruits

39.  Physical examination
 Dry vs Wet Gangrene
Dry gangrene Wet gangrene
Dry, shriveled, mummified Odematous, putrified and
discoloured
Occurs due to slow and gradual loss
of blood supply
Occurs due to sudden loss of blood
supply
Clear line of demarcation is present Vague/ No line of demarcation
No proximal extention Proximal extension
Limited amputation High amputation

40.  Physical examination
 Dry vs Wet Gangrene

41.  ABPI

42.  ABPI
 Physiological testing
SBP of PT/PT/PA (higher)
--------------------------------- = ABPI
Higher of the two brachial SBPs
 Normal value =>1
 Claudication <0.9
 Rest pain <0.5
 Imminent necrosis <0.3
 Note:
 Normal value doesn’t rule out ischemia
 Retest after exercise, ABPI may fall
 Wrong high readings in calcified arteries, e.g. seen in diabetics &ESRD

43.  ABPI
 Note:
 Normal value doesn’t rule out ischemia
 Retest after exercise, ABPI may fall
 Post exercise ABPI considered POSITIVE when
 ABPI fall => 0.2 and/or
 Failure to return to baseline in 3 minutes
 Wrong high readings in calcified arteries, e.g. seen in diabetics
&ESRD

44.  Segmental pressure
Difference of 20-30 mmHg is indicative of significant lesion

45.  Photo-Plethysmography
 Investigation for segmental flow
 Infra-red light emitting source + a photosensor
 Light decreases when flow increases
 Generates a pressure and waveform of different arteries
 A difference of 20-30 mmHg is significant.

46.  Doppler Ultrasound
(DU)
 Continous wave DU with
segmental waveforms
 Doppler shift converted to
audio signal
 Normal  Triphasic Signal
 Sharp systolic upstroke
 Reversal of flow in early
diastole
 Low amplitude forward
flow throughout
diastole.

47.  Doppler Ultrasound (DU)
 Obstructive disease
 Initial Loss of reversal flow in early diastole (Bi-phasic)
 Severe  blunting of arterial waveform with decreased amplitude
 Worsening  only diastolic flow (Mono-phasic )
 In case of a proximal obstruction/ stenosis
 Assessment downstream is less accurate
 Shows moving blood but it may/ may not be
sufficient

48.  Doppler Ultrasound
(DU)

49.  Duplex Ultrasound
 Provides with B mode settings (gray settings)
 Pulsed Doppler spectral waveforms
 Can even detect very low flow states
 Color flow data and waveforms for analysis by a computer.
 Shows blood flow and turbulence
 Peak systolic velocities (PSV) and End diastolic velocities are
recorded.

50.  Duplex Ultrasound
 Change in waveforms
 Triphasic  biphasic  Monophasic
 Ratio of PSV proximal and distal to occlusion
 >2.0 indicates a stenosis of 50% or more
 Difficult in aoto-illiac segments, especially in obese
individuals
 (patient should fast overnight)

51.  Angiography
 Invasive techique of visualising the arterial tree
 Hypaque 45 (Sodium Diatrazoate) is used as a dye (75 to 100
ml)
 Course of arteries, constrictions, and distal “Run off”
 To plan interventions
1. Transfemoral
2. Trans-lumbar (established bi-lateral obstruction)
 Seldinger technique is used

52.  Angiography
 Done in 4 stages
i. Dye released at the level of diaphragm in the aorta
 Abdominal aorta
 Celiac artery
 Sup mesenteric artery
 Inferior mesenteric artery
ii. Dye released at aortic bifurcation
 B/L common iliac arteries
 Hypogastric arteries
 External iiliac arteries
 Common femoral arteries
 Sup Femoral arteries
 Profunda femoris

53.  Angiography
 Done in 4 stages
iii. Contralateral common femoral artery
 Contralateral Sup Femoral artery
 Profunda femoris
 Popliteal artery
 3 crural arteries
 Pedal arteries
iv. Ipsilateral common Femoral artery
 Sup Femoral artery
 Profunda femoris
 Popliteal artery
 3 crural arteries
 Pedal arteries

54.  Angiography
 Site of block in
Atherosclerosis

55.  Angiography
 Cork-screw pattern of
vessels in TAO
 Block at multiple sites
in small and medium
sized arteries

56.  Angiography
 Risk / Complications:
a) Groin hematoma
b) Retroperitoneal bleeding
c) Pseudo-anuerysm
d) Arterial dissection
e) Contrast nephropathy
f) Contrast allergy

57.  CT angiography
 IV contrast followed by Ct imaging
 Thin slices of 0.625mm
 Allows 3-D reconstruction
 Improved speed
 Lesser contrast material
 Appreciation of thrombus, calcification, etc. better
 Disadvantages similar to angiography

58.  Digital subtraction angiography (DSA)
 Angiographic images being digitilised by a computer
 With substraction of extrenous background (bone, soft
tissues)

59.  MR angiography
 Uses Godalinium as contrast
 Better sensitivity and specificity
 Disadvantages:
 longer study duration
 Costlier
 Metallic implants contra-indication
 Nephrotoxic contrast
 Fibrosed nodules of skin, eyes and joints (rare complication)

60.  Carbon Dioxide angiography
 CO2 as contrast agent
 In cases of renal insuffieciency
 CO2 temporarily displaces blood but dissolves in 3-5
minutes
 Poor detail
 Significant patient discomfort
 Gas trapping mesenteric ischemia

61.  General Investigations
 ECG
 ECHO
 Lipid profile
 COPD
 Blood tests to exclude
 Anemia
 DM
 Deranged RFT
 High blood viscosity (polycythemia and thrombocythemia)

62.  Intravascular
ultrasound (IVUS)
 Catheter based
intravascular
ultrasound
 Provides transverse and
360 degree image of the
lumen of the vessel
 Qualitative data about
the wall anatomy

63.  Brown’s vasomotor index
 For Buerger’s disease
 Test of vasospasm
 Block the nerves with Local anesthesia to predict
efficacy of Sympathectomy
 Rise in skin temperature is recorded
 Index = Rise in skin temperature – Rise of mouth temperature
Rise of mouth temperature
 Index =>3.5 is positive for sympethectomy

64.  Conservative management
 Indications:
 Ankle pressure >60mmHg
 Femoral pulse +
 No rest pain
 No tissue loss
 Controlled infection (eg diabetic patient)
 Unfit for surgery
 ABPI >0.5 (Relative indication)

65.  Conservative management
 Stop smoking
 Keep walking
 Reduce weight (obese individuals)
 Exercise
 Diabestes and hypertension
 Care of feet
 Buerger’s position
 Buerger’s exercise

66.  Conservative management
 Drugs
 Analgesics- Aspirin
 Vasodialtors
 Cilostazol (phosphodiasterase inhibitors)
 Pentoxyphylline (phosphodiasterase inhibitors)
 Prostacycline
 Platelet aggregation inhibitors
 Clopidrogel
 Aspirin
 Prostacycline

67.  Conservative management
 Drugs
 To Control
 Diabetes
 Hypertension
 Dyslipidemia
 Atherosclerosis
 Infection
 Note: Risk of limb Loss to be explained to the patient
(Failure in 25% of patients)
 Opening up of collaterals or change of gait with less usage
of the affected muscle

68.  Indirect surgeries
 Sympathectomy
 Chemical
 Surgical
 Indications:
 Rest pain
 Skin ulcerations
 TAO
 Elderly patient (senile gangrene)

69.  Indirect surgeries
 Sympathectomy
 Chemical
 Produces cutaneous vasodilatation
 Injection in front of the lumbar fascia which contains
sympathetic trunk; Under C-Arm
 5ml phenol in water is inected in front of 2nd, 3rd and 4th
lumbar vertebra

70.  Indirect surgeries
 Sympathectomy
 Surgical (pre-ganglionic sympathectomy)
 Abdomen opened with oblique incision under genral
anasthesia
 Dissection through flat abdominal muscles, and peritoneum
 The sympathic chain is situated medial to the medial margin
of psoas muscle
 Rt side  overlapped by IVC
 Lt side  overlapped by aorta
 Sympathetic chain identified by the presence of ganglia
 First lumbar ganglia is as high as crus of the diaphragm

71.  Indirect surgeries
 Sympathectomy
 Surgical
 Sympathectomy from 1 to 4th lumbar ganglion
 Closed the site in layers
 Note: in case of bilateral surgery; preserve L1 of atleast one
side  causes retrograde ejaculation.

73.  Surgical Management
 Surgical Revascularization Procedures
 Open
 Endo-vascular
 Amputation

74.  Surgical Revascularization Procedures
 Open vs endo-vascular
 Trans-Atlantic Inter Society Documentation Management
of Peripheral Arterial Disease (TASC) 2000
 TASC –II in 2007
“Endovascular therapy is the treatment of choice for
Type A lesions and surgery is the treatment of choice
for Type D lesions. Endovascular treatment is the
preferred treatment for Type B lesions and surgery is
the preferred treatment for good risk patients with
Type C lesions”

75.  TASC –II (Aorto-iliac)

76.  TASC –II (Aorto-iliac)

77.  TASC –II (Aorto-iliac)

78.  TASC –II (Aorto-iliac)

79.  TASC –II (Femoro-popliteal)

80.  TASC –II (Femoro-popliteal)

81.  TASC –II (Femoro-popliteal)

82.  TASC –II (Femoro-popliteal)

83.  Open Surgical Management (Aorto-iliac disease)
 Aorto-bifemoral bypass with a prosthetic graft via
transabdominal or retroperitoneal approach.
 End to end or end to side proximal anastomosis
 Nervi erigentes should be taken care of (damage will
lead to retrograde ejaculation) in the area of CIA
 Mortality 5%

84.  Open Surgical Management
 Choice of Graft (Conduits)
 Great Sephanous vein
 Preferred for lower limbs with better patency rates (90% First
yr and 60% five yrs)
 Should preferentially be used in all below knee by-passes
 Can be used in situ
 Better size match
 Removal of valves with valvulotome
 Reversed
 No need of disruption of valves
 May be harvested endoscopically
 No added advantage of one over the other

85.  Open Surgical Management
 Choice of Graft (Conduits)
 PTFE (Polytetrafluoroethylene)
 Can be used as a replacement of LSV
 Poorer results compared to LSV (50% in five yrs)
 New: with heparin coating
 Dacron is a brand name of PTFE

86.  Open Surgical Management
 Choice of Graft (Conduits)
 Small sephanous vein
 Basillic vein
 Cephalic vein
 All these three veins have very thin walls, hence no good
results
 veins when joined to increase the length gives poor results
 Cryo-preserved arteries
 Cadevaeric arteries preserved in cold
 Bovine pericardial patches

87.  Open Surgical Management (Aorto-iliac disease)
 Aorto-bifemoral bypass
 Midline or transverse abdominal incision
 CFA and branches exposed through groin incision
 Small bowel retracted to right
 Posterior peritoneum is open
 Retroperitoneal tunnels are made to groin.
 Heparin 5000U given iv bolus and vessels clamped

88.  Open Surgical Management (Aorto-iliac disease)
 Aorto-bifemoral bypass
 Vertical incision on anterior aspect of Aorta
 Dacron sutured end to side (taking all the layers)
 The Limbs fed to the groin sutured end to side to CFA
 Posterior peritoneum closed over peritoneum

89.  Aorto-bifemoral bypass

90.  Open Surgical Management (femoro-popliteal)
 Open groin surgery
 CFA endarectomy + profundoplasty/ iliofemoral bypass
 In case of added proximal (iliac) occlusion
 CFA endarectomy + profundoplasty / iliofemoral bypass
+ iliac stenting
 In case of added distal (SFA)occlusion
 CFA endarectomy + profundoplasty +SFA stenting/
femoropopliteal bypass

91.  Open Surgical Management
 Endarterectomy
 Open:
 When it involves short segment of big arteries
 Also called “dis-obliteration/ reboring”
 Heparin 5000U given pre-opeartively
 Artery is exposed after placing clamps
 Distal clamp applied first
 Longitudinal incision taken oven the occlusion till the plaque
is reached

92.  Open Surgical
Management
 Endarterectomy
 Open:
 Plane created between
plaque and media
 The plaque is removed
with the diseased intima
 In case of thrombus, it is
removed
 Closed with non
absorbable fine sutures
directly or a vein graft
 Post op anticoagulant
therapy with warfarin

93.  Open Surgical Management
 Endarterectomy
 Closed
 Artery exposed and clamped
 Proximal and distal transverse incisions taken
 Plane created between plaque and tunica media
 Wire loop passed from distal to lower arteriotomy insion,
stripping the plaque
 Can be used in relatively longer occlusions

94.  Open Surgical Management
 Endarterectomy
 Balloon
 Artery is exposed after clamping
 Proximal arteriotomy is made
 Fogarty ballon catheter is passed

95.  Open Surgical
Management
 Endarterectomy
 Passed beyond the
obstruction
 Ballon is inflated
 Pulling the catheter
removes the atheroma
 More commonly used
for emboli (as they are
comparetively loosely
adherant)

96.  Open Surgical Management
 Profundoplasty
 Repairing of profunda femoris
 Arises posterior to CFA
 The vessel is dissected out and clamps are applied
 Arteriotomy extending from CFA to distal to occlusion
 Atherectomy is then performed

97.  Open Surgical
Management
 Profundoplasty
 Defect is them closed by
a vein patch
 On table angiography is
then performed to check
for patency
 May be done in adjunct
to bypass surgeries

98.  Open Surgical Management
 Femoro-popliteal bypass
 In patients with SFA and popliteal artery occlusion with a distal
segment of patent popliteal artery.
 In continuity with any crural artery
 Longitudinal groin incision to access the CFA
 Popliteal artery is exposed medially from thigh or the leg
 In above knee bypass, incision proximal to the knee to access
popliteal artery
 In below knee bypass, popliteal fossa is opened

99.  Femoro-popliteal
bypass
 Polpileat vein is held in
Silastic loops
 Graft is tunnelled and
placed at the
anastomotic site
 Sephanous vein graft
can be used
 In situ (requires
desruption of valves)
 Reversed, can be
accessed by a parallel
skin incision

100.  Open Surgical Management
 Infrapopliteal bypass
 Disease involving popliteal artery and proximal tibial arteries.
 the target artery must have luminal continuity with the foot
 Stenosis upto 50% is accepted as patent for surgery
 Calcification also not considered a contra-indiaction.
 SFA or Popliteal artery is used for “inflow”

101.  Open Surgical Management
 Infrapopliteal bypass
 Access to PTA with dissection and separation of Soleal muscle
attachment from tibea  access to PTA and PA
 Access to ATA with anterolateral incision on legseparation of
ant tibial muscle and external longus muscle ATA.
Separation of interosseus membrane for tunneling of the graft.
 Small veins can be used for anastomosis
 Or PTFE graft can be used

102.  Open Surgical Management
 Other bypasses
A. Axillofemoral graft
 Tunnelled subcutaneously between the axillary artery
proximally, to reachone or both CFA
 Low patency rates
B. Femoro-femoral crossover bypass
 Crossover graft by tunnelling a prosthetic graft
subcutaneously above the pubis between the groins

104.  Endovascular management
 Basically involves gaining access into transmural space
via percutaneous femoral artery puncture
 Balloon angioplasty
 Subintimal angioplasty
 Stenting
 Stent graft
 Variations of balloon angioplasty

105.  Endovascular management
 Balloon angioplasty
 Guide wire is negotiated through the stenosis or occlusion
 Then a balloon is inflated to open the occlusion
 It is kept inflated for approx 1 minutes with high pressure
then deflated
 May be combined with stenting

106.  Endovascular management
 Balloon angioplasty
 Very good results for dilating the iliac and
femporopopliteal segments
 Below knee procedures are less successful
 98% success in CLI (extremely good results)
 Limb salvage rate of 91% over 5 fyrs
 Failure in TASC D patients

107.  Endovascular management
 Subintimal angioplasty
 Creating an arterial dissection purposely begenning at the
proximal end of the oclusion
 The guide wire is made to re-enter the lumen at the
diastal end of occlusion
 Use of balloon angioplasty to increase the diameter of the
false lumen
 Poor results
 3 yrs patency rates being only 30%
 But good for critical limb ischemia

108.  Endovascular management
 Subintimal angioplasty

109.  Endovascular management
 Stenting
 If the vessel fail to remain dilated use stents
 Stainless steel stents
 May be introduced on a balloon catheter and placed in
position
 Self expanding stents (nitinol), which expand on
withdrawing the sheath
 Angioplasty (balloon) + stenting > primary stenting
 But primary stenting > only angioplasty
 Poor results in TASC D patients

110.  Endovascular management
 Stenting

111.  Endovascular management
 Stenting

112.  Endovascular management
 Stent garft
 Expanded PTFE (ePTFE) with external nitinol stent
 Inner surface bonded with heparin
 Extremely flexible
 Can close conform to the shape of artery (esp: SFA)
 Self expanding stents
 Easier with better patency rates than atherectomy.
 It is easier, with more better technical succes comapred t o
PTA
 Few studies show similar results comapred to bypass

113.  Endovascular
management
 Cutting balloon
 Originally designed for
coronary arteries
 The balloon has three or
four atherotomes or
micro-surgical blades
 These are mounted
longitudinally on the
balloon
 The blades score the
lesion and dilate the
lesions

114.  Endovascular management
 Cryoplasty
 Apoptosis by cooling
 Designed by Polar Cath Peripheral Dilatation System
(Boston Scientific)
 Balloon filled with nitrous oxide gas
 To cool to -10 degrees C
 Supposed to prevent restenosis

115.  Endovascular management
 Endovascular atherectomy
 Excision atherectomy catheters remove and collect the atheroma
 Ablative atherectomy device fragment it
 Rotational cutters turn at the speed of 8000rpm to shave the plaque
and collect in a storage chamber
 Laser atherectomy has a cold tipped laser that delivers burst of
ultraviolet Xenon energy in short pulse durations
 Results same as balloon angioplasty

116.  Endovascular management
 Endovascular atherectomy
Rotational cutter Laser tipped

117.  Amputation
 Indication for amputation
 Dead Limb
 Gangrene
 Deadly Limb
 Wet gangrene
 Spreading cellulitis
 Dead Loss Limb
 Severe rest pain with
 Ischemia
 Paralysis
 Contracture

118.  Amputation
 Choice of amputation
 Below knee amp[utation (BKA)
 Above knee amputation (AKA
 Ray amputation
 Transmetatarsal amputation
 Miscellaneous
 Syme’s
 Chopart’s
 Lisfranc’s

119.  Amputation
 Level of amputation
 Skin perfusion pressure >=40 mmhg
 Transcuatneous oxygen pressure >= 30mmhg
 Predictors for Transmetatarsal amputation:
 Toe Blood Pressure >=30 mmhg
 Ankle Blood Pressure >= 80 mmHg

120.  Amputation
Below Knee Amputation Above Knee Amputation
Poor Healing Better Healing
More chances of revision/
healing by secondary intention
Less chances of revision
Better ambualtion Poor ambulation

121.  Amputation
 Ray amputation

122.  Amputation
A. Syme’s
B. Chopart’s
C. Lisfranc’s
D. Transmetatarsal