CRITICAL LIMB CRITICAL LIMB ISCHEMIAISCHEMIA

Definition and WorkupDefinition and Workup

Presented by;Presented by;

Sultan Al SheikhSultan Al Sheikh

DefinitionDefinition

Inadequate arterial Inadequate arterial blood flow to blood flow to accommodate the accommodate the metabolic needs of metabolic needs of resting tissueresting tissue

Two important Two important variables:variables:

1.1. clinical symptoms clinical symptoms

2.2. measured circulatory measured circulatory

impairmentimpairment

DefinitionDefinition

TASC definition:TASC definition:

persistent , recurring ischemic rest pain persistent , recurring ischemic rest pain requiring opiate analgesia for at least 2 wk requiring opiate analgesia for at least 2 wk

ulceration or gangrene of the foot or toes, ulceration or gangrene of the foot or toes, and ankle systolic pressure less than and ankle systolic pressure less than

50 mmHg or toe systolic pressure less than 50 mmHg or toe systolic pressure less than 30 mmHg ( or absent pedal pulses in 30 mmHg ( or absent pedal pulses in patients with DM) patients with DM)

CLICLI

Mortality rate : Mortality rate :

claudication is 50% at 5yclaudication is 50% at 5y

CLI 70% at 7y and 85% at 10yCLI 70% at 7y and 85% at 10y

classificationclassification

Traditional Fontaine classification system:Traditional Fontaine classification system:

I AsymptomaticI Asymptomatic

II ClaudicationII Claudication

III Ischemic rest painIII Ischemic rest pain

IV Ischemic ulceration/necrosisIV Ischemic ulceration/necrosis

CLICLI

Fontaine stage III & IV:Fontaine stage III & IV:

rest pain rest pain

pedal necrosis : ischemic ulceration or pedal necrosis : ischemic ulceration or

necrosisnecrosis

Documentation of circulatory impairment Documentation of circulatory impairment

CLICLI

Circulatory impairment ( TASC ) :Circulatory impairment ( TASC ) :

1.1. ankle pressure less than 50 to 70 mmHgankle pressure less than 50 to 70 mmHg

2.2. Toe pressure less than 30 to 50 mmHgToe pressure less than 30 to 50 mmHg

3.3. Transcutaneuos partial pressure of Transcutaneuos partial pressure of oxygen at the foot is less than 30 to oxygen at the foot is less than 30 to

50 mmHg 50 mmHg

CLICLI

CLI can progresses directly from fontaine I CLI can progresses directly from fontaine I to stage III & IVto stage III & IV

Dormandy ( multicenteric) : Dormandy ( multicenteric) :

50% were asymptomatic 6 m before 50% were asymptomatic 6 m before

major amputation for CLImajor amputation for CLI

In general CLI inevitably progress to limb In general CLI inevitably progress to limb

loss without revascularisation loss without revascularisation

CLICLI

At least 2 or more levels of severe arterial At least 2 or more levels of severe arterial occlusion.occlusion.

Usually fempop or infrapop occlusion Usually fempop or infrapop occlusion ( adjacent vascular bed )( adjacent vascular bed )

or superficial femoral and deep fem or superficial femoral and deep fem (parallel beds) (parallel beds)

ATHEROSCLEROSISATHEROSCLEROSIS

AgeAge

Male gender Male gender

DMDM

SmokingSmoking

hypertentionhypertention

HyperlipidemiaHyperlipidemia

HyperfibrinogenemiaHyperfibrinogenemia

HyperhomocysteinemiaHyperhomocysteinemia

hypercoagulabilityhypercoagulability

Rest PainRest Pain

DefinitionDefinition

Age Age

SexSex

SymptomsSymptoms

H/O claudicationH/O claudication

Previos HistoryPrevios History

Family HistoryFamily History

Rest PainRest Pain

General appearanceGeneral appearance

Local exam:Local exam:

horizontal------- pale,guttered veinshorizontal------- pale,guttered veins

dependent------deep reddish-purpledependent------deep reddish-purple

pressure areaspressure areas

temp. capillary refilling. Pulsestemp. capillary refilling. Pulses

auscultationauscultation

GangreneGangrene

Dead tissueDead tissue

Line of demarcationLine of demarcation

Infected ( wet gangrene)Infected ( wet gangrene)

Non-infected ( dry gangrene )Non-infected ( dry gangrene )

UlcerationUlceration

Causes:Causes:

large-artery obliteration: atherosclerosis , large-artery obliteration: atherosclerosis , embolism.embolism.

small-artery obliteration: raynauds small-artery obliteration: raynauds diseas, scleroderma, Buergers diseas, scleroderma, Buergers disease,embolism, radiation, electric burn.disease,embolism, radiation, electric burn.

UlcerationUlceration

PositionPosition

TendernessTenderness

TemperatureTemperature

SizeSize

EdgesEdges

BaseBase

DepthDepth

DischargeDischarge

Relations:bare bone Relations:bare bone or tendon at the baseor tendon at the base

Cardiac and cerebrovascular Cardiac and cerebrovascular evaluationevaluation

Systemic nature of atherosclerosisSystemic nature of atherosclerosis

must be assessed in all pt with new onset must be assessed in all pt with new onset PADPAD

Duplex for carotids ( 28% significant Duplex for carotids ( 28% significant stenosis in pt with infrainguinal bypass)stenosis in pt with infrainguinal bypass)

Clinical predictors of increased CV Clinical predictors of increased CV risk: MI,HF,deathrisk: MI,HF,death

MAJORMAJOR

1.1. Unstble coronary Unstble coronary syndromesyndrome

2.2. Decompensated HFDecompensated HF

3.3. Significant Significant arrhythmiasarrhythmias

4.4. Severe valvular Severe valvular disease disease

IntermediateIntermediate

1.1. Mild anginaMild angina

2.2. Previous MIPrevious MI

3.3. Compensated HFCompensated HF

4.4. DMDM

5.5. Renal insufficiecyRenal insufficiecy

Clinical predictors of increased CV Clinical predictors of increased CV risk: MI,HF,deathrisk: MI,HF,death

MinorMinor1.1. Advanced age Advanced age 2.2. Abnormal ECG (LT vent. Hypertrophy, Abnormal ECG (LT vent. Hypertrophy,

LBBB)LBBB)3.3. Rhythm other than sinus Rhythm other than sinus 4.4. Low functional capacityLow functional capacity5.5. H/O strokeH/O stroke6.6. Uncontrolled HTNUncontrolled HTN

EvaluationEvaluation

Surgical or percutaneous intervention:Surgical or percutaneous intervention:

symptomssymptoms

co-morbidityco-morbidity

locationlocation

severityseverity

EvaluationEvaluation

Segmental arterial pressure and ABISegmental arterial pressure and ABI presence presence locationlocation supranormal ABIsupranormal ABI correlate with pulse volume recording and toe correlate with pulse volume recording and toe

pressurepressure little benefit in planning interventionlittle benefit in planning intervention

Exercise testExercise test

In pt palpable pulses but disabling In pt palpable pulses but disabling symptomssymptoms

ankle pressure at restankle pressure at rest

treadmill at 3.5 km/h treadmill at 3.5 km/h

measure again measure again

Duplex imagingDuplex imaging

Non invasive , low cost , operator Non invasive , low cost , operator dependentdependent

Delineate arterial anatomy and blood flowDelineate arterial anatomy and blood flow

Aly and colleage ( 90 pts)Aly and colleage ( 90 pts)

sens. 92% and spec. 99% for occlusionsens. 92% and spec. 99% for occlusion

sens 89% and spec 98% for lesion lengthsens 89% and spec 98% for lesion length

Contrast intra arterial subtraction Contrast intra arterial subtraction angioangio

Most commonly used for planning Most commonly used for planning interventionintervention

Complete visualzationComplete visualzation

Risks:Risks:

reaction 0.1%reaction 0.1%

mortality 0.16%mortality 0.16%

Complications of angiographyComplications of angiography

Puncture sitePuncture site

hemorrhage/hematomahemorrhage/hematoma

pseudoaneeurysmpseudoaneeurysm

arteriovenous fistulaarteriovenous fistula

atherembolizationatherembolization

local thrombosislocal thrombosis

Complications of angiographyComplications of angiography

Contrast relatedContrast related

major sensitivity reaction ( anaphylactoid)major sensitivity reaction ( anaphylactoid)

minor reactionminor reaction

vasodilation / hypotesionvasodilation / hypotesion

nephrotoxicitynephrotoxicity

hypervolemia ( osmotic ) hypervolemia ( osmotic )

MRIMRI

Gadolinium enhancedGadolinium enhancedEntire arterial tree , including pedal vesselsEntire arterial tree , including pedal vesselsSuperior for patent distal vesselsSuperior for patent distal vesselsDifficulties:Difficulties:

metallic implantsmetallic implants claustrophobia claustrophobia gadoliniumgadolinium

More cost effective ( in considering angioplasty)More cost effective ( in considering angioplasty)Angiograph superior for planning surgeryAngiograph superior for planning surgery

THANK YOUTHANK YOU