Chronic critical limb ischemia is manifested by pain at rest, nonhealing wounds and gangrene. Ischemic rest pain is typically described as a burning pain in the arch or distal foot that occurs while the patient is recumbent but is relieved when the patient returns to a position in which the feet are dependent

1. CHRONIC LOWER LIMB ISCHEMIA

2. ANATOMY
1. Aortoiliac
segment (inflow)
2. Femoropopliteal
segment
3. Infrapopliteal
segment
(outflow)

3. INTRODUCTION
• Chronic Limb ischemia
= Decrease in limb perfusion > 2 weeks
2007 Trans-Atlantic Inter-Society Consensus for the
Management of Peripheral Arterial Disease (TASC II)
• Aetiology: Atherosclerosis (90%)
• May present at any point along a scale of
severity:
Mild
Intermittent
Claudication
Rest pain
Ischaemic
skin
changes
Gangrene
of large
part of
limb
** 2 distinct
entities:
Intermittent
claudication
(IC)
Critical Limb
Ischaemia
(CLI)

4. (A) INTERMITTENT CLAUDICATION
5% people over 60 y.o.
(only 1-2%
deteriorates)
Ddx: neurogenic;
venous claudication
Definition of IC
- Muscular pain
- Not present at rest
- Comes on walking a
particular distance
(claudication distance)
- Quickly relieved by
resting
- Repetitive
Mx:
Best Medical Therapy
(BMT) – risk factor
modification
Surgical/endovascular
intervention only after
6 month compliance to
BMT

6. CRITICAL LIMB ISCHEMIA
• Multiple lesions affecting different arterial segments
• Features:
– Rest pain
– Tissue loss (ulcer/gangrene)
– Low Ankle Brachial Pressure Index (<0.5)
• Fontaine III & IV

7. ISCHEMIC ULCERS VENOUS ULCERS
PAIN Yes, unless neuropathic Minimal; not intolerable
DURATION Less than 6 weeks Often months/years
PAST HISTORY Cardiac ischemia/CABG
common
DVT/ severe varicose veins
LIMB SIGNS
SWELLING Not swollen unless pt has
been sleeping in a chair to
relieve pain
Usually non-pitting plus
pitting edema unless
effective bandaging in
place
TEMPERATURE Usually cold Usually normal or warm
PULSES Absent; low Doppler
pressure *ABSI/ABPI
Present; normal Doppler
pressure
ULCERS
SITE Toes, dorsum of foot Gaiter’s area
MARGIN Punched out Irregular with blue margin
& growing epithelium
BASE Destroy deep fascia & may
expose tendons, with poor
granulation
Beefy red, shallow and
never penetrate deep
fascia, pale granulation
tissue

8. MANAGEMENT
NON- SURGICAL MANAGEMENT
Pharmaco Non-pharmaco
SURGICAL MANAGEMENT
Minimally invasive Invasive
Stop
smoking
Hypertension
control
Hypercholester
olemia control
Antiplatelet
agent
Regular
exercise
Obesity
control
Diabetes
identification
& active
treatment
Foot care
Best Medical
Therapy (BMT)
-endaarterectomy
-Balloon angioplasty
with/without stenting
-Bypass surgery
(arterial
reconstruction)
- Amputation

10. Buerger’s Disease
Non-atherosclerotic, idiopathic,
recurrent, segmental
inflammatory, vasculopathy of
medium & small sized arteries
& veins of upper & lower
extremities
Diabetic Foot
Combination of ischemia,
neuropathy, &
immunocompromise that
renders the feet of diabetic pt
susceptible to sepsis, ulceration
& gangrene.
Challenges in diabetic vascular
disease:
- Calcified
- Reduce ability to fight
infection
- Multisystem
- Infrapopliteal vessels
- Co-existing neuropathy

11. REFERENCES
• Principles & Practice of Surgery
• Essentials Surgery
• Inter-Society Consensus for the Management of Peripheral
Arterial Disease (TASC II), L. Norgren et. al., Eur J Vasc
Endovasc Surg Vol 33, Supplement 1, 2007
• Review Articles: Critical limb ischemia, Varu et. al., Journal
of Vascular Surgery, 2010
• Chronic lower limb ischemia, J.D. Beard, BMJ 2000