introduction to chronic ischemia

Chronic ischemia
introduction
by
Mohammed Salah
Ass .lecturer –vas .surgery department

Etiology
1. Atherosclerosis
2. Arteritis as in case of :
Thrombangitis obliterance (Burger’s disease)
Rheumatoid arthritis Systemic lupus erythematosis
Scleroderma Kawaski syndrome
Takayaso syndrome
3. Vasospastic diseases:
Reynaud's disease Reynaud's phenomena
4. Chronic on top of acute

Risk factors: Lipid abnormalities
2 X
Diabetes
4 X
Smoking
3X
Age >65
2 X
Risk of developing
CLI

Method of palpating dorsalis pedis pulse.
Examine pulse from the foot of the bed, keeping the
fingers flat for the dorsalis pedis , while applying
counterpressure with the thumb.
The dorsalis pedis artery lies superficially on the dorsum
of the foot, although its position varies considerably.

Method of palpating posterior tibial pulse.
Examine pulse from the foot of the bed, using the
fingertips for the posterior tibial, while applying
counterpressure with the thumb.
The posterior tibial artery lies deeper behind the medial
malleolus. Many healthy people have only one foot
pulse.

Method of palpating popliteal artery with patient's knee slightly flexed.
Use thumbs to apply counterpressure while palpating the artery, which lies deep in
popliteal fossa, with fingers.
The popliteal pulse can be difficult to palpate in muscular patients.
A prominent popliteal pulse suggests the possibility of a popliteal aneurysm.

Method of palpating femoral pulse in skin crease of
groin.
Counterpressure on the lower abdomen pushes
the skin crease towards the inguinal ligament and
reduces the risk of missing the puls

Angiogram showing bilateral occlusions of superficial femoral arteries in thighs.
Collaterals arising from the profunda femoris artery can functionally bypass this
occlusion

Fontaine classification of chronic leg
ischaemia
Stage I Asymptomatic
Stage II Intermittent claudication
A - walking distance >200m
B - walking distance <200m
Stage III Ischaemic rest pain
Stage IV Ulceration or gangrene, or
both

0.9-1.3 Asymptomatic
0.6-0.9 Claudication
0.4-0.6 Claudication
0.2-0.4 Rest pain
<0.2 Impending tissue loss
Ankle brachial index interpretation

Gangrene associated with critical limb

Foot ulcer associated with critical limb ischaemia

Physical Examination:
Examination: What do to:
Inspection
Expose the skin
and look for:
• Thick Shiny Skin
• Hair Loss
• Brittle Nails
• Colour Changes (pallor)
• Ulcers
• Muscle Wasting
Palpation • Temperature (cool, bilateral/unilateral)
• Pulses: ?Regular, ?AAA
• Capillary Refill
• Sensation/Movement
Auscultation • Femoral Bruits
Ankle Brachial
Index (ABI)
= Systolic BP in ankle
Systolic BP in brachial artery
Buerger’s Test • Elevate the leg to 45° - and look for pallor
• Place the leg in a dependent position 90°& look
for a red flushed foot before returning to normal
• Pallor at <20° = severe PAD.

What does the ABI mean?
ABI Clinical Correlation
>0.9 Normal Limb
0.5-0.9 Intermittent Claudication
<0.4 Rest Pain
<0.15 Gangrene
CAUTION:
Patient’s with Diabetes + Renal Failure:
They have calcified arterial walls which can falsely elevate their ABI.

Chronic lower extremity ischemia represents a
clinical spectrum:

Critical Limb Ischemia:
 Our concern (no intervention, amputation is inevitable).
 The term CLI was first coined by the first international
symposium in London 1981.
 it implies only chronicity (TASC II recommendation 16).
 Fontaine 3 and 4.
 SVS/ ISCVS:
1-rest pain and resting ankle pressure < 40 mmhg, toe
pressure < 30 mmhg.
2- minor tissue loss (non healing ulcer, focal gangrene)
resting ankle pressure < 60 mmhg, toe pressure < 40 mmhg

 3- major tissue loss ( extending above the
Transmetatarsal level, foot is no longer salvageable)
resting ankle pressure < 60 mmhg, toe pressure < 40
mmhg
 European working group definition:
1- severe rest pain requiring opiate analgesics for at least
2 weeks
2- ulceration or gangrene
3- ankle pressure < 50 mmhg or toe pressure < 35 mmhg.

Investigations:
NON INVASIVE:
Duplex Ultrasound
 normal is triphasic  biphasic  monophasic  absent
BLOOD TESTS:
1. FBE/EUC/Homocysteine Levels
2. Coagulation Studies
3. Fasting Lipids and Fasting Glucose
4. HBA1C
WHEN TO IMAGE:
1. To image = to intervene
2. Pt’s with disabling symptoms where revascularisation is considered
3. To accurately depict anatomy of stenosis and plan for PCI or Surgery
4. Sometimes in pt’s with discrepancy in hx and clinical findings

ANGIOGRAPHY:
Non-invasive:
• CT Angiogram
• MR Angiogram
Invasive:
• Digital Subtraction Angiography
 Gold Standard
 Intervention at the same time

Tardus et parvus = small amplitude + slow rising pulse

CT Angiography Digital Subtraction Angiography
Value of angiography
Localizes the obstruction
Visualize the arterial tree & distal
run-off
Can diagnose an embolus:
Sharp cutoff, reversed meniscus or clot
silhouette

Short occlusion of left popliteal artery treated by percutaneous transluminal angioplasty.

The balloon catheter is passed through the occlusion over a guide wire and inflated.

Treatment:
1. RISK FACTOR MODIFICATION:
a) Smoking Cessation
b) Rigorous BSL control
c) BP reduction
d) Lipid Lowering Therapy
3. MEDICAL MANAGEMENT:
a) Antiplatelet therapy e.g.
Aspirin/Clopidogrel
b) Phosphodiesterase Inhibitor e.g.
Cilostazol
c) Foot Care
2. EXERCISE:
a) Claudication exercise
rehabilitation program
b) 45-60mins 3x weekly for 12 weeks
c) 6 months later +6.5mins walking
time (before pain)

introduction to chronic ischemia

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