Chronic Limb Ischaemia Flashcards
What is CLI most commonly caused by?
Atherosclerosis in lower limbs.
Epidemiology
15-20% of individuals over 70 have CLI
Increases with age
More common in males
Risk factors
Smoking
DM
HTN
Hyperlipidaemia
Increasing age
FH
Obesity and physical inactivity
Stages of CLI
Stage I = Asymptomatic
Stage II = Intermittent claudication
Stage III = Ischaemic rest pain
Stage IV = Ulceration or gangren or both
This is called Fontaine classification
What is Buerger’s test
Lie the patient supine and raise their legs until they go pale
Lower them until colour returns
The angle at which limb goes pale is called Buerger’s angle
An angle of <20 degrees indicates severe ischaemia
What is Leriche syndrome?
A form of peripheral arterial disease affecting the aortic bifurcation
This leads to buttock or thigh pain + ED
What is critical limb ischaemia?
The advanced form of CLI
Define critical limb ischaemia
Ischaemic rest pain for greater than 2 weeks duration
Presence of ischaemic lesions or gangren
ABPI < 0.5
Examination of critical limb ischaemia
Pale and cold
Weak or absent pulses
Hair loss
Skin changes with atrophic skin, ulceration aor gangren
Thickened nails
Dx
Spinal stenosis
ALI
Investigation
Diagnosis is clinical
Ankle-Brachial Pressure Index is used to confirm diagnosis and quantify severity.
Doppler USS should be done and possible CT angiography as well.
Cardiovascular risk assessment, BP, serum glucose, lipids and ECG should also be done.
Explain ABPI
Compares the blood pressure of the brachial artery and the ankle.
It’s a ratio that quantifies severity of the ischaemia.
Normal = >0.9
Mild = 0.8-0.9
Moderate = 0.5-0.8
Severe = <0.5
Medical management
Lifestyle advice with smoking cessation, regular exercise and weight loss
Atorvastatin 80mg OD
Clopidogrel 75mg OD
Optimise diabetes control
Supervised exercise programme
Indications of surgical management
Can be offered if risk factor modifications has been discussed and supervised exercise has failed to improve symptoms.
Critical limb ischaemia should be urgently referred for surgical intervention.
Two main surgical approaches
Angioplasty +/ stenting
Bypass grafting
Combination of the two
Amputation if beyond repair
