critical limb ischemia definition and workup presented by; sultan al sheikh
TRANSCRIPT
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