Chronic Limb Ischaemia

Question 1

Chronic limb ischaemia epidemiology

Answer 1

5% men >50 years get intermittent claudication

Question 2

Definition of chronic limb ischaemia

Answer 2

• Ankle artery pressure <50mmHg (toe <30mmHg)
  AND either:
• Persistent rest pain requiring analgesia for ≥2wks
• Ulceration or gangrene§

Question 3

Causes of chronic limb ischaemia

Answer 3

Atherosclerosis

Rarely vasculitis

Question 4

Presentation of chronic limb ischaemia

Answer 4

1) Intermittent claudication
2) Critical limb ischaemia (fontaine 3/4)
3) Leriche’s syndrome
4) Buerger’s syndrome

Question 5

Intermittent claudication

Answer 5

Cramping pain after walking set distance

calf = superficial femoral disease, buttock = iliac disease

Question 6

Critical limb ischaemia

Answer 6

Rest pain (night), ulceration, gangrene

Question 7

Leriche’s syndrome

Answer 7

Aortoiliac occlusive disease
Triad: 
-Buttock claudication/wasting
-Erectile dysfunction
-Absent femoral pulses

Question 8

Buerger’s disease

Answer 8

Thromboangiitis Obliterans
Young, male, smoker
Acute inflammation and thrombosis of arteries/veins in hands and feet –> ulceration and gangrene

Question 9

Signs of chronic limb ischaemia

Answer 9

-Pulses: weak pulses and ↑ CRT (norm ≤2sec)
-Ulcers: painful, punched-out, on pressure points.
-Nail dystrophy / Onycholysis
-Skin: cold, white, atrophy, absent hair
-Venous guttering
-Muscle atrophy
-↓ Buerger’s Angle (lift leg until pale):
≥90: normal
20-30: ischaemia
<20: severe ischaemia
- Buerger’s Sign: Reactive hyperaemia due to accumulation of deoxygenated blood in dilated capillaries

Question 10

Fontaine classification of chronic limb ischaemia

Answer 10

1) Assymptomatic
2) Intermittent claudication: a. >200m b.<200m
3) Ischaemic rest pain
4) Ulceration/gangrene

Question 11

Rutherford classification of chronic limb ischaemia

Answer 11

1) Mild claudication
2) Moderate claudication
3) Severe claudication
4) Ischaemic rest pain
5) Minor tissue loss
6) Major tissue loss

Question 12

Investigations for chronic limb ischaemia

Answer 12

Doppler waveforms
Ankle Brachial Pressure index
Walk test
Bloods
Imaging: colour duplex US, CT/MR angiogram with gadolinium contrast, digital subtraction angiography

Question 13

Doppler waveforms

Answer 13

Normal: triphasic
Mild stenosis: biphasic
Severe stenosis: monophasic

Question 14

Treatment of chronic limb ischaemia

Answer 14

Conservative
Medical: aim to reduce risk factors. Can use beta blockers in intermittent but not critical limb ischaemia, antiplatelets, analgaesia.
Endovascular: percutaneous transluminal angioplasty/stenting
Surgical reconstruction.