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Chronic limb ischemia
This document provides an overview of chronic limb ischemia, including: - The anatomy of the arteries of the upper and lower limbs. - The main causes of chronic limb ischemia are atherosclerosis, thromboangiitis obliterans, aorto-arteritis, and Raynaud's disease. Risk factors include age, smoking, diabetes, hypertension, and hyperlipidemia. - Clinical features include pain, paresthesia, pallor, absent pulses, skin changes, ulcers, and gangrene. Diagnosis involves history, examination of pulses and skin, Doppler ultrasound, and angiography. Management depends on the severity and includes risk factor modification, medications, angioplasty, stenting
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Chronic limb ischemia
- 1. CHRONIC LIMB ISCHEMIA PROF. DR.A.B.SINGH UNIT Department of Surgery Patna medical college & hospital
- 2. CONTENT Anatomy ofarteries of the limbs Etiology Clinical features History Clinical Examination Investigations Management
- 3. ARTERIES OF UPPERLIMB ARTERIES OF LOWER LIMB Profunda fermoris Palmar Arches
- 4. Chronic Limb ischemia =Decreased limb perfusion for > 2 weeks 2007 Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) ETIOLOG Y LOWER LIMB ISCHEMIA •Atherosclerosis •thrombangiitis obliterans UPPER LIMB ISCHEMIA •Aorto-arteritis (Takayasu arteritis ) •Raynaud's disease •Thoracic outlet obstruction •Other rarer causes mixed cryoglobulinemia, nodular periarteritis, dermatomyositis, systemic scleroderma SENILE ATHEROSCLEROSIS IS COMMON IN BOTH LOWER AND UPPER LIMB
- 5. RISK FACTORS OldAge (>70 yrs) Male gender Diabetes Smoking Hypertension Hypercholesterolemia Hypertriglyceridemia Hyperhomocysteinemia Sedentary Lifestyle Family History Fatty diet Drugs ( beta blockers, OCP )
- 6. ATHEROSCLEROSIS It isa chronic complex inflammatory condition of elastic and muscular arteries, involving as systemic and segmental. Common arteries involved are— infrarenal part of abdominal aorta, coronary arteries, iliofemoral vessels, carotid bifurcation, popliteal arteries. It is less common in upper limb arteries, common carotid, renal and mesenteric arteries. Brief pathophysiology Lipid deposition calcification Erosive area& 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
- 8. THROMBOANGIITIS OBLITERANS SYN. BUERGER’SDISEASE exclusively seen in males of young age group with history of smoking. Almost always starts in lower limb, may start on one side and later on the other side. Only upper limb involvement can occur (not uncommon) but it is rare. segmental, progressive, nonatherosclerotic inflammatory occlusive, disease of small and medium sized vessels with superficial thrombophlebitis often may present with microabscesses, along with neutrophil and giant cell infiltration, with skip lesions. Intermittent claudication in foot and calf progressing to rest pain, ulceration, gangrene. Recurrent migratory superficial thrombophlebitis. Absence/feeble pulses distal to proximal; dorsalis pedis, posterior tibial, popliteal, femoral arteries. May present as Raynaud’s phenomenon.
- 9. Smoking Causes vasospasmand hyperplasia of intima Thrombosis and obliteration of vessels occur, commonly medium sized vessels are involved Panarteritis is common .Usually involvement is segmental Eventually artery, vein and nerve are together involved Nerve involvement causes rest pain Patient presents with features of ischaemia in the limb If patient continues to smoke, disease progresses into the collaterals, blocking them eventually, leading to severe ischaemia and is called as decompensatory peripheral vascular disease. PATHOGENESIS critical limb ischaemia. It causes rest pain, ulceration, gangrene
- 10. Classification of THROMBOANGIITIS OBLITERANS TypeI: Upper limb TAO—rare. Type II: Involving leg/s and feet crural/infrapopliteal. Type III: Femoropopliteal. Type IV: Aortoiliofemoral. Type V: Generalised. Shianoya’s criteria for Buerger’s disease 1. Tobacco use. 2.Only in males 3. Disease starts before 45 years 4. Distal extremity involved first without embolic or atherosclerotic features 5. Absence of diabetes mellitus or hyperlipidaemia 6. With or without thrombophlebitis
- 11. THORACIC OUTLET SYNDROME Causesof thoracic outlet syndrome Cervical rib Long C7 transverse process Anomalous insertion of scalene muscles Scalene muscle hypertrophy Scalene minimus Abnormal bands and ligaments Fracture clavicle or first rib Exostosis Tumours in the region Cervical rib
- 12. THORACIC OUTLET SYNDROME Arterialcompromise Fatigue Weakness Coldness Upper limb claudication Thrombosis Paraesthesia Raynaud's phenomenon due to thrombosis with distal embolisation Venous compromise Edema Venous distension Collateral formation Cyanosis Paget-Schroetter syndrome – effort thrombosis Neural compromise Paraesthesia Pain in shoulder, arm, forearm and fingers Occipital headache – referred from tight scalene muscles Weakness of forearm, hand
- 13. TAKAYASU’S PULSELESS ARTERITIS Progressive,initially symptomless panarteritis, probably immunological. common in young females (85%); common in Japan; subclavian artery (85%); involves all layers of arteries; often bilateral. Fever, myalgia, arthralgia, upper limb claudication & hypertension. Absence pulses in upper limb/limbs, neck Fainting on turning the neck or change in position; atrophy of face. Optic nerve atrophy without papilloedema. Weakness and paraesthesia of upper limb. DSA; MR angiography and Doppler are the investigations. To suppress immunity prednisolone 50 mg/day and cyclophosphamide daily is given.
- 14. RAYNAUD’S DISEASE: Itis seen in females, usually bilateral. It occurs in upper limb with normal peripheral pulses. It is due to upper limb (hand) arteriolar spasm as a result of abnormal sensitivity to cold. Patient develops blanching, cyanosis and later flushing as in Raynaud’s syndrome. Occasionally if spasm persists it results in gangrene. Symptoms can be precipitated and observed by placing hands in cold water. Types of Raynaud’s phenomenon Vasospastic Obliterative Raynaud’s syndrome Local syncope Local asphyxia Local recovery Local gangrene
- 15. CHRONIC LIMB ISCHEMIAIN DIABETES Thrombosis can be precipitated by infection causing infective gangrene. High glucose level in tissues A good culture media for bacteria Diabetic microangiopathy blockade of microcirculation Diabetic neuropathy Glycosylated haemoglobin Increased in blood causes defective oxygen dissociation Limb Ischemia Diabetic Atherosclerosis ULCER Infection Loss of sensation Blockage occurs at plantar, tibial, and dorsalis pedis vessels Hypoxia
- 16. CLASSIFICATION OF LIMB ISCHEMIA Functional Normal blood flow at rest, but cannot be increased in response to exercise – Claudication Three main clinical features Pain is always experienced in muscle It is reproducibly precipitated by walking Symptoms are promptly relieved by rest Chronic critical limb ischemia Recurring ischemic pain at rest that persists for more than 2 weeks and requires regular analgesics with an ankle systolic pressure of 50 mm Hg or less Ulceration or gangrene of the foot or toes
- 17. PRESENTATION AND DIAGNOSIS OF CHRONICLIMB ISCHEMIA !!
- 18. DEMOGRAPHY OF CLINICAL SYMPTOMS ~15% Classical(Typical) Claudication ~33% Atypical Leg Pain (functionally limited) 50% Asymptomatic 1%-2% Critical Limb Ischemia
- 19. CLINICAL PRESENTATIONS Pain(most common symptom) – on walking (Intermittent claudication / Rest pain Paraesthesia Pallor Diminished or absent pulse Cold limb ( Poikilothermia) Diminished hair , brittle nail , thinning & shining of skin Small Ulcer Gangrene
- 20. HISTORY RELATED TOCHRONIC LIMB ISCHEMIA Age : old age – atherosclerosis , young Age : TAO Pain ( intermittent/ continuous) Numbness / tingling / altered sensation Coldness of lower limbs Later on Ulcer / blackening of part of lower limb other H/O – Fainting / Blackout/ Blurring of vision - Abdominal pain /chest pain - Difficulty in breathing - Weakness in upper limb - Failure of erection Past History : Hypertension / Diabetes/ CVA
- 21. Boyd’s Classification Claudicationof Pain Grade I – Patient develops pain on walking. But if he continues to walk, the pain disappears. This is due to the washing away of the Substance P Grade I I– Patient develops pain on walking. But if he continues to walk, the pain persists. But the patient can still walk with some efforts. Grade I I I– Patient develops pain on walking. The pain compels the patient to take rest. Leriche – Fontaine clinical Classification Stage I : asymptomatic patient; Stage II: intermittent claudication; Stage III: pain during rest, lowered in orthostatism. Stage IV: trophic changes ( ulcerations, gangrene) and permanent pain. Rutherford classification Grade Clinical feature 0 Asymptomatic 1 Mild claudication 2 Moderate claudication 3 Severe claudication 4 Ischaemic rest pain 5 Minor tissue loss 6 Major tissue loss
- 22. Characteristic features ofClaudication pain o 1. Always precipitated by activity o 2. Relieved by taking rest o 3. It is a cramp like pain felt over the muscles o 4.Is always reproducible. Claudication Distance It is the distance travelled by a person with Peripheral Occlusive Vascular Disease before the onset of Pain. It is thought to be due to the accumulation of Substance P and Lactic acid. Factors Affecting Claudication Distance Claudication Distance Decreases when- There is increased Speed of walking- Resistance offered for walking- Walking up hill Poor General Health & Systemic diseases of the patient
- 23. Pain upto Buttock, hip Thigh, upper2/3rd calf lower1/3rdCalf, Obstruction level Aorta or iliac artery(30%) Femoral artery or branches(60%) Tibial & dorsalis pedis artery Level of Claudication according to the site of obstruction Popliteal artery Ankel & foot
- 24. CLAUDICATION VS. PSEUDOCLAUDICATION Claudication Pseudoclaudication Characteristicof discomfort Cramping, tightness, aching, fatigue Same as claudication plus tingling, burning, numbness Location of discomfort Buttock, hip, thigh, calf, foot Same as claudication Exercise-induced Yes Variable Distance Consistent Variable Occurs with standing No Yes Action for relief Stand Sit, change position Time to relief <5 minutes ≤30 minutes
- 25. DIFFERENTIAL DIAGNOSIS OFLEG PAIN Vascular a) Chronic venous insufficiency Neurospinal a) Degenerative disc Disease b) Spinal canal Stenosis (Pseudoclaudication) Neuropathic a) Diabetes b) Chronic alcohol abuse Musculoskeletal a) OA (variation with weather + time of day) b) Chronic compartment syndrome Miscellaneous a) Restless leg syndrome b) Symptomatic baker’s cyst
- 26. Rest Pain Rest Painis the pain felt even at rest. It is due to the Ischemia of the somatic nerves(cry of the dying nerves) Rest pain Felt in the foot (most distal parts) 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 as the gravity aids in the blood flow to the nerves. Patient may commit suicide hen-holding
- 27. Examination: What doto: Inspection Expose the skin and look for: • Colour Changes (pallor) • Thick Shiny Skin • Hair Loss • Brittle Nails • Muscle Wasting • Ulcers- number, site, shape, size ,margin ,edge ,floor • Gangrene :type, colour, extent, line of demarcation Palpation • Temperature (cool, bilateral/unilateral) • Sensation/Movement • Pulses: ?Regular,?diminished or absent • Capillary Refilling time(normal: <2 sec) • Venous refilling time( Harvey sign) Auscultation • Systolic bruit may be heard over stenosed artery like subclavian artery, femoral artery, carotid artery, iliac, renal artery. Buerger’s postural Test • Ask the Patient lying in supine position to raise his leg and look for development of pallor • In normal individuals pallor do not develops even at 90° • Buerger’s angle of vascular insufficiency: It is the angle in which pallor develops on raising legs. • If this angle is < 30°, it indicates severe ischaemia.
- 28. CLINICAL EXAMINATION PulseExamination Carotid Radial/ulnar Femoral Popliteal(cross leg test) Dorsalis pedis Posterior tibial Scale: 0=Absent 1=Diminished 2=Normal 3=Bounding (aneurysm or AI)
- 29. Abdomen should beexamined for the presence of abdominal aortic aneurysms. It presents as pulsatile mass above the umbilicus, vertically placed, smooth, soft, nonmobile, not moving with respiration, resonant on percussion. Expansile pulsation is confirmed by placing the patient in knee-elbow position. Hyperabduction manoeuvre (Wright test) Allen’s testAdson’s test (Scalene manoeuvre) Elevated arm stress test (EAST) modified Roos test Costoclavicular compression manoeuvre (Falconer test):
- 31. It is macroscopicdeath of tissue in situ with or without putrefaction. 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 Infection not present Infection present offensive odor) Cold temp. ,dull aching pain skin changes colour to dark brown→ dark purplish→ completely dark offensive odor Swollen, red and warm Clear line of demarcation is present Vague/ No line of demarcation No proximal extention Proximal extension Limited amputation High amputation
- 32. INVESTIGATION Routine Bloodinvestigation sugar , urea , creatinine Serum cholesterol , Triglyceride Urine sugar X- ray of lower limb – calcification of vessels, condition of underlying bone Ankle-Brachial Index Usg Duplex Arteriography Biopsy of the vessels Other investigation - USG whole abdomen - ECHO - ECG Recent Advances in investigations Xenon 133 Isotopes scanning Trans-cutaneous oximetry
- 33. HEMODYNAMIC NONINVASIVE TESTS RestingAnkle-Brachial Index (ABI) Exercise ABI Segmental pressure measurement These traditional tests continue to provide a simple, risk-free, and cost-effective approach to establishing the limb ischemia diagnosis as well as to follow up after the procedures.
- 35. EXERCISE ABI Confirmsthe limb ischemia diagnosis Assesses the functional severity of claudication May “unmask” limb ischemia when resting the ABI is normal
- 36. INTERPRETATION OF ANKLE/ BRACHIAL INDICIES (ABI’S) Normal ABI 0.9 – 1.2 Mild limb ischemia ABI 0.7 – 0.9 Minimal symptoms Moderate limb ischemia ABI 0.4 – 0.7 Claudication Severe limb ischemia ABI < 0.4 Rest pain, Tissue loss Non-compressible ABI > 1.2
- 37. SEGMENTAL PRESSURE MEASUREMENTS SegmentalBP is measured at multiple levels (upper and lower thigh, upper calf and ankle); pressure reductions between levels help to localise the occlusion; normally pressures increase as one moves further down the leg (>20 mmHg gradient abnormal); test is inaccurate in calcified artery walls.
- 38. ARTERIAL DUPLEX ULTRASOUND TESTING However,the data that might support use of duplex ultrasound to assess long-term patency of PTA is not robust. STENOSIS OF SUPERIOR FEMORAL ARTERY BLOCKAGE OF FEMORAL ARTERY It is combination of B mode ultrasound and Doppler study. Difference in transmitted beam of the ultrasound and reflected beam is called as Doppler shift which is assessed and converted into audible signals. It is used to study the site, extent, severity of block, and also about collaterals.
- 39. ANGIOGRAPHY produces a roadmap of the blood vessels. Shows site ,extent and severity of blockage In Thrombangitis Oblitrans corkscrew apperance Distal run-off inverted tree/ spider leg apperance Corrugated , ripped artery TYPES Free flush Selective Collaterals
- 40. Blockage at right commoniliac Artery
- 41.
- 42. TREATMENT OF THORACIC OUTLETSYNDROME Non operative treatment Posture improving exercises. Breathing exercises. Avoid aggravating activities. Avoid repetitive upper extremity mechanical work and muscular trauma. Analgesics,muscle relaxants, antidepressants. Physiotherapy . Surgical Indications: Symptoms persists with non operative treatment. Associated vascular compression. Progression of neurological symptoms. Nerve conduction velocity < 60m/s Trans cervical or trans axillary (Roos) resection of 1st rib often with release of scalene muscles. Cervical rib excision.
- 43. TREATMENT Life stylemodification Stop smoking Supervised exercise Regular walk Fat free diet Weight reduction limb care buerger’s excercise foot cleaning Application of mousteriser Avoid precipitating factors— Cold/ Drugs Strict control of Blood pressure Blood sugar Cholesterol
- 45. MEDICAL TREATMENT Vasodialators– Nifedipine Xanthinol nicotinate Pentoxifylin 400 mg TDS PO Decreases blood viscocity Increases flexibity of RBC Anti-Plateletes Drugs Low dose Asprin 75 mg OD PO Clopidogrel 75 mg OD PO Cilastazole - 100 mg BD PO Hypolipidimics - Atrovastatin 10- 40 mg OD PO ANALGESICS
- 46. Indications: claudication interfering withlifestyle critical limb ischemia Angioplasty : Conventional Sub- intimal End artrectomy : Open Semiclosed Weily eversion technique Stenting Arterial bypass Graft : Natural : Insitu sephanous Reverse sephanous Artificial : Anatomical Extra Anatomical Amputation :
- 47. SUMMARY OF PREFERREDOPTIONS
- 48. PERCUTANEOUS TRANSLUMINAL BALLOON ANGIOPLASTY(PTA): It is useful in cases of localised stenosed areas. Through trans femoral Seldinger approach, initially angiogram is done. Then under guidance (fluoroscopic) stenosed area is approached. Balloon of the angioplasty catheter is inflated at stenosed area for one minute and repeated if required. Plaques should rupture. Catheter is withdrawn.
- 49. ENDARTERECTOMY For focal/isolated block It is removal of thrombus along with diseased intima through an arteriotomy. Endothelium of the vessel is removed, hence the name. There are three methods— (1) Open method (2) Semi-closed (3) Wiley’s eversion endarterectomy Advantages are—it avoids prosthetic graft and its complications—reocclusion and restenosis.
- 50. PROFUNDAPLAS TY: localised blockin opening of profunda femoris (deep femoral). Profunda femoris is opened, thrombus if present, is removed. Opening is widened using either venous or synthetic (Dacron or PTFE) grafts.
- 51. ARTERIAL/VENOUS GRAFTS: Synthetic Dacronwoven /knitted graft Dacron coated PTFE—polytetrafluoroethylene graft Natural Long saphenous vein either reverse or in situ Umbilical vein graft (cryopreserved)—3 mm vein is the minimum diameter required
- 52. REVERSE SAPHENOUS VEINGRAFT Advantages over synthetic graft Better patency rate ( 5 yr rate : 60% compared to 50% of synthetic graft ) Less prone to thrombus Lesser tendency to dilate Disadvantage : High skill required More morbid procedure Early Graft Necrosis ( rare now )
- 53. ANATOMICAL BYPASS Femoro-popliteal bypassgraft Aortofemoral bypass graft Aortofemoral Femoropopliteal Poplitealtibial Complication Hemorrhage Adjacent organ damage Autonomic nerve damage Cardiac/Renal/Respiratory Failure Colonic/ pelvic ischemia Aorto-enteric Fistula
- 54. EXTRA-ANATOMIC BYPASS Axillofemoral Axillobifemoral bypass Femoral-Femoral bypass Axillobifemoral bypassAxillofemoral bypass Indications : 1.Difficulty in Abdominal / retroperitoneal access 2.Abdominal infection/malignancy 3.Pt . Unfit for major vascular surgery
- 55. LUMBAR SYMPATHECTOMY: Indications: Peripheralvascular disease like TAO. To promote healing of cutaneous ulcers. To change level of amputation and to make flaps to heal better after amputation. Causalgia of lower limb (it is common in upper limb). Chemical sympathectomy: It is done in lateral position using a long spinal needle under local anaesthesia. Position is confirmed by injecting dye under fluoroscopy. Later 5 ml of phenol in water or absolute alcohol is injected lateral to the vertebral bodies of fourth and second lumbar vertebrae. Care should be taken to see that the needle does not enter IVC or aorta. Procedure is contraindicated in patients with bleeding disorders and in patients who are on anticoagulants.
- 56. OMENTOPLAS TY It promotesulcer healing, reduces the pain and controls the features of ischaemia. It can also be used in upper limb ischaemia. If patient continues to smoke, disease spreads to these omental vessels also. Complications of omentoplasty: 1.Abdominal sepsis. 2. Incisional hernia, 3.Adhesions and intestinal obstruction.
- 57. AMPUTATIONS Indications- Gangrenous Non salvageablelimb Evaluation of the Patients who need Amputation 1. Haematocrit, 2.control of anaemia by transfusing blood/ packed cells. 3.Control of infection using antibiotics. 4.Decision of level of amputation by skin temperature, arterial Doppler. 5.Informed consent should be taken. 6.Plan for prosthesis and rehabilitation by physiotherapist and rehabilitation team.
- 58. FACTORS INFLUENCING SURGICAL TREATMENTRESULTS Age Atherogenic risk factors Co-morbidities Clinical indication for treatment Severity of ischemia Segmental anatomy of arterial occlusive disease Choice of treatment (open or endovascular) Technical difficulty Choice of materials