The document discusses peripheral artery disease (PAD), specifically critical limb ischemia (CLI). It defines CLI as a severe form of PAD involving ischemic rest pain, ulcers, or gangrene lasting over 2 weeks due to reduced blood flow. CLI is diagnosed using ankle-brachial pressure index testing or angiography and treated through risk factor modification, pharmacotherapy, and revascularization to relieve pain, heal ulcers, and prevent limb loss. The primary goals of CLI treatment are to improve symptoms, function, and survival.

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.
50

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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