CRITICAL LIMB ISCHEMIA

DEFINITION
chronic ischemic at-rest pain, ulcers, or gangrene in one or both legs attributable to objectively proven arterial occlusive disease

REST PAIN
Occurs with the limb at rest Exacerbated by elevation or lying down Worse at night

ULCERS
Painful erosion between toes or Shallow non-healing ulcers on dorsum of feet, shins especially around the malleoli

GANGRENE
Death of macroscopic portions of the tissues

OBJECTIVE CRITERIA
One of the following must be present for the diagnosis
more than two weeks of recurrent foot pain at rest that requires regular use of analgesics and is associated with an ankle systolic pressure of 50 mm Hg or less, or a toe systolic pressure of 30 mm Hg or less

OR a non healing wound or gangrene of the foot or toes,

with similar hemodynamic measurements.

HEMODYNAMIC PARAMETERS

an ankle-brachial index of 0.4 or less, an ankle systolic pressure of 50 mm Hg or less, or a toe systolic pressure of 30 mm Hg or less.

CAUSES
Atherosclerosis Hypercholesterolemia cigarette smoking Diabetes Buerger's disease arteritis Acute conditions
an embolus thrombosis

DIAGNOSIS
History Physical examination
absent or diminished pedal pulses, shiny smooth skin of the feet and legs, muscle wasting of the calves.

INVESTIGATIONS
Ankle or toe systolic pressure Ankle brachial index Arteriography/ CTA/ MRA

MANAGEMENT OPTIONS
Conservative treatment Operative intervention
Revascularization amputation

Conservative Treatment
Risk factor modification including
smoking cessation, blood pressure control, good glycemic control and reduction of lipid levels, should be instituted.

 Antiplatelet therapy with aspirin has been shown to substantially decrease the risk of myocardial infarction, stroke and death in patients with peripheral vascular disease and also reduces the rate of arterial re occlusion after angioplasty or bypass grafting.

Nonhealing Wounds
Infected wounds require antibiotic therapy, surgical debridement, or both. includes teaching the patient ways to avoid trauma to the wound site, including the wearing of properly fitting shoes. Dressings

REVASCULARIZATION
Feasibility of revascularization Angioplasty or stent placement, or both,
most successful with short, proximal lesions

Bypass
Vein, artificial conduit

PRIMARY AMPUTATION
in patients with extensive tissue necrosis, life-threatening infection or lesions not amenable to revascularization.

 the level of amputation should be one that has the greatest likelihood of healing while giving the patient the maximal chance for functional rehabilitation

FOLLOW UP
After amputation or revascularization, patients require rehabilitation to hasten their return to maximal independence.

QUESTIONS

GANGRENE

DEFINITION
Macroscopic death of tissues Necrosis is microscopic

CLINICAL FEATURES
Pulse less Cold Sensory loss Absence of function Colour changes from pale to final black

TYPES OF GANGRENE
Dry
Ischemic Shrivelled, dry, line of demarcation

Moist
In the presence of infection Swollen, blebs crepitus

SPECIFIC VARIETIES
DIABETIC GANGRENE
Ischemic Infection neuropathy

 BED SORES
Caused by local pressure Ischemic, anemia, malnutrition Prophylaxis is important May need debridement and subsequent plastic surgical procedures

 FROST BITE
Exposure to cold Damage to vessel wall Blistering followed by gangrene Slow warming Conservative amputations

 VENOUS GANGRENE
Due to massive outflow obstruction in veins Extensive DVT

TREATMENT OF ISCHEMIC GANGRENE

Spontaneous separation
Especially for digits Keep dry Relieve pain Avoid local pressure

Amputation