CHRONIC LIMB ISCHEMIA

PROF. DR. A.B.SINGH UNITDepartment of Surgery

Patna medical college & hospital

CONTENT Anatomy of arteries of the limbs Etiology Clinical features History Clinical Examination Investigations Management

ARTERIES OF UPPER LIMB ARTERIES OF LOWER LIMB

Profunda fermoris

Palmar Arches

Chronic Limb ischemia = Decreased limb perfusion for > 2 weeks

2007 Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)

ETIOLOGYLOWER LIMB ISCHEMIA Atherosclerosis thrombangiitis obliterans

UPPER LIMB ISCHEMIA Aorto-arteritis (Takayasu arteritis )Raynaud's disease Thoracic outlet obstructionOther rarer causes mixed cryoglobulinemia, nodular periarteritis, dermatomyositis, systemic scleroderma

SENILE ATHEROSCLEROSIS IS COMMON IN

BOTH LOWER AND UPPER LIMB

RISK FACTORS

Old Age (>70 yrs) Male gender Diabetes Smoking Hypertension Hypercholesterolemia Hypertriglyceridemia Hyperhomocysteinemia Sedentary Lifestyle Family History Fatty diet Drugs ( beta blockers, OCP )

ATHEROSCLEROSIS It is a 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

THROMBOANGIITIS OBLITERANS SYN. BUERGER’S DISEASE 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.

Smoking Causes vasospasm and 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 ischaemiaand is called as decompensatory peripheral vascular

disease.

PATHOGENESIS

critical limb ischaemia. It causes rest pain, ulceration, gangrene

Classification of THROMBOANGIITIS OBLITERANS Type I: 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 males3. Disease starts before 45 years4. Distal extremity involved first without embolic or atherosclerotic features5. Absence of diabetes mellitus or hyperlipidaemia6. With or without thrombophlebitis

THORACIC OUTLET SYNDROMECauses of 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

THORACIC OUTLET SYNDROMEArterial compromise 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

TAKAYASU’S PULSELESS ARTERITISProgressive, 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.

RAYNAUD’S DISEASE:

It is 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

CHRONIC LIMB ISCHEMIA IN DIABETES

Thrombosis can be precipitated by infection causing infective gangrene.

High glucose level in tissues

A good culture media for bacteria

Diabetic microangiopath

y

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

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

PRESENTATION AND DIAGNOSIS OF CHRONIC LIMB ISCHEMIA !!

DEMOGRAPHY OF CLINICAL SYMPTOMS

~15%Classical (Typical) Claudication

~33%Atypical Leg Pain(functionally limited)

50%Asymptomatic

1%-2%Critical Limb Ischemia

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

HISTORY RELATED TO CHRONIC 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

Boyd’s Classification Claudication of 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 classificationGrade Clinical feature0 Asymptomatic1 Mild claudication2 Moderate claudication3 Severe claudication4 Ischaemic rest pain5 Minor tissue loss6 Major tissue loss

Characteristic features of Claudication paino 1.  Always precipitated by activityo 2. Relieved by taking resto 3. It is a cramp like pain felt over the muscleso 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 DistanceClaudication Distance Decreases when-    There is increased Speed of walking-     Resistance offered for walking-     Walking up hill    Poor General Health & Systemic diseases of the patient 

Pain upto

Buttock, hip

Thigh,upper2/3rd calf

lower 1/3rdCalf,

Obstruction level

Aorta oriliac artery(30%)

Femoral arteryor branches(60%)

Tibial & dorsalis pedis artery

Level of Claudication according to the site of obstruction

Popliteal artery

Ankel & foot

CLAUDICATION VS. PSEUDOCLAUDICATION

Claudication PseudoclaudicationCharacteristic of discomfort

Cramping, tightness, aching, fatigue

Same as claudication plus tingling, burning,

numbnessLocation of discomfort

Buttock, hip, thigh, calf, foot

Same as claudication

Exercise-induced Yes VariableDistance Consistent VariableOccurs with standing No YesAction for relief Stand Sit, change positionTime to relief <5 minutes 30 minutes

DIFFERENTIAL DIAGNOSIS OF LEG PAIN

Vasculara) Chronic venous insufficiency

Neurospinala) Degenerative disc Diseaseb) Spinal canal Stenosis (Pseudoclaudication)

Neuropathica) Diabetesb) Chronic alcohol abuse

Musculoskeletala) OA (variation with weather + time of day)b) Chronic compartment syndrome

Miscellaneousa) Restless leg syndromeb) Symptomatic baker’s cyst

Rest PainRest Pain is 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 footWorse at night; patient sits in “hen-holding” positionPressure of even bed clothes worsens the painLessened 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

Examination: What do to: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.

CLINICAL EXAMINATION Pulse Examination

Carotid Radial/ulnar Femoral Popliteal(cross leg test) Dorsalis pedis Posterior tibial

Scale: 0=Absent 1=Diminished 2=Normal 3=Bounding (aneurysm or

AI)

Abdomen should be examined 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):

It is macroscopic death of tissue in situ with or without putrefaction.

Dry gangrene Wet gangreneDry, shriveled, mummified Odematous, putrified and

discolouredOccurs 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 odorSwollen, red and warm

Clear line of demarcation is present Vague/ No line of demarcationNo proximal extention Proximal extensionLimited amputation High amputation

INVESTIGATION Routine Blood investigation

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

HEMODYNAMIC NONINVASIVE TESTS

Resting Ankle-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.

EXERCISE ABI Confirms the limb

ischemia diagnosis

Assesses the functional severity of claudication

May “unmask” limb ischemia when resting the ABI is normal

INTERPRETATION OF ANKLE / BRACHIAL INDICIES (ABI’S)

Normal ABI 0.9 – 1.2Mild limb ischemia ABI 0.7 – 0.9Minimal symptomsModerate limb ischemia ABI 0.4 – 0.7

ClaudicationSevere limb ischemia ABI < 0.4

Rest pain, Tissue lossNon-compressible ABI > 1.2

SEGMENTAL PRESSURE MEASUREMENTS

Segmental BP 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.

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.

ANGIOGRAPHY produces a road map 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

Blockage at right common iliac Artery

TREATMENT OF CHRONIC LIMB

ISCHEMIA

TREATMENT OFTHORACIC OUTLET SYNDROME

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.

TREATMENT Life style modification 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

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

Indications: claudication interfering with lifestyle 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 :

SUMMARY OF PREFERRED OPTIONS

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.

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.

PROFUNDAPLASTY:

localised block in 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.

ARTERIAL/VENOUS GRAFTS:

Synthetic Dacron woven /knitted graft Dacron coated PTFE—polytetrafluoroethylene graftNatural Long saphenous vein either reverse or in situ Umbilical vein graft (cryopreserved)—3 mm

vein is the minimum diameter required

REVERSE SAPHENOUS VEIN GRAFTAdvantages 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 requiredMore morbid procedure Early Graft Necrosis ( rare now )

ANATOMICAL BYPASS

Femoro-popliteal bypass graft Aortofemoral bypass graft

Aortofemoral Femoropopliteal Poplitealtibial

Complication Hemorrhage Adjacent organ damage Autonomic nerve damageCardiac/Renal/Respiratory Failure Colonic/ pelvic ischemia Aorto-enteric Fistula

EXTRA-ANATOMIC BYPASS

Axillofemoral Axillobifemoral bypass Femoral-Femoral bypass

Axillobifemoral bypass

Axillofemoral bypass

Indications :1.Difficulty in Abdominal / retroperitoneal access2.Abdominal infection/malignancy3.Pt . Unfit for major vascular surgery

LUMBAR SYMPATHECTOMY:

Indications: Peripheral vascular 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 bleedingdisorders and in patients who are on anticoagulants.

OMENTOPLASTY

It promotes ulcer 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.

AMPUTATIONS Indications- Gangrenous Non salvageable limb

Evaluation of the Patients who need Amputation1. 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.

FACTORS INFLUENCING SURGICAL TREATMENT RESULTS

AgeAtherogenic risk factorsCo-morbiditiesClinical indication for treatmentSeverity of ischemiaSegmental anatomy of arterial occlusive

diseaseChoice of treatment (open or endovascular)Technical difficultyChoice of materials