CHRONIC LIMB

ISCHAEMIC
Dokter Muda:
Dedy Sutriyatno

Pembinging :
Dr. Ivan J. Sp.BTKV
Teachmesurgery.com

■ Definition
■ Risk factor
■ Critical limb ischaemia
■ Differential diagnosis
■ Investigation
■ Management: Medical and surgical management
■ Complications
DEFINITION & EPIDEMIOLOGY

■ Chronic limb ischaemia is peripheral arterial disease that results in a symptomatic

reduced blood supply to the limbs.
■ It is typically caused by atherosclerosis (rarely vasculitis)
■ Commonly affect the lower limbs
■ ~15-20% individuals over 70 years have peripheral arterial disease.
■ Framingham study demonstrated an incerase in the prevalence of the disease from 0.4
per 1000 males aged 35-45 years to 6 per 1000 males aged >65 years.
RISK FACTORS

■ Smoking
■ Diabetes mellitus
■ Hypertension
■ Hyperlipidaemia
■ Age
■ Family history
■ Obesity and physical inactivity
CLINICAL FEATURES
Fontaine Classification of Chronic Leg Ischaemia

Stage I Asymtomatic

Stage II Intermittent claudication

Stage III Ischaemic rest pain

Stage IV Ulceration or gangrene, or both

Buerger’s test an angle of less than 20 degress indicates

severe inschaemia
 CRITICAL LIMB ISCHAEMIA

CRITICAL LIMB ISCHAEMIAthe advanced

form of chronic limb ischaemia. It can be clinically
defined in three ways:
■ Ischaemic rest pain for greater than 2 weeks
duration, requiring opiate anagesia.
■ Presence of ischaemic lesion or gangrene
objectively attributabel to the arterial occlusive
■ ABPI < 0.5

On examination, the limbs may be pale & cold, with weak or

absent pulses. Other sign include limb hair loss, skin changes
(atrophic skin, ulceration, or gangrene), and thickened nails
DIFFERENTIAL DIAGNOSES

SPINAL STENOSIS ALI

 Typically have pain from  Clinical features that < 14
the back radiating down days duration, often
the lateral aspect of the presenting within hours.
leg (tensor fascia lata),
 Symptoms on initial
movement or symptoms
that are relieved by sitting
rather than standing
INVESTIGATIONS
The diagnosis of chronic limb ischaemia is clinical. The ankel-brachial pressure index
(ABPI) is used to confirm the diagnosis & quantify severity of chronic limb ischaemia

SEVERI ABPI
TY
Normal >0.9
Mild 0.8 – 0.9
Moderate 0.5 – 0.8
severe <0.5
 MANAGEMENT : Medical
Most patients with chronic limb ischaemia require cardiovascular
risk factor modification

Lifestye advice Statin therapy

Anti-platelet therapy Optimise diabetes control

The course of chronic limb ischaemia is variable & many patients’

symptoms do improve on lifestyle changes & medical management
alone
MANAGEMENT : Surgical
NICE guidance states that surgical intervention can be offered in
suitable patients if

Supervised exercise has failed to improve symtoms

Any patients with critical limb ischaemia
MANAGEMENT : Surgical
There are two main surgical options available

ANGIOPLAST BYPASS
Y GRAFTING
Amputation are considered for any patients who are unsuitable for
revascularion wih ischaemia causing incurabel symptoms or
gangrene leading to sepsis
COMPLICATION
Chronic limb ischaemia can result in sepsis (secondary to infected
gangrene), acute on chronic ischaemia, and reduced mobility &
quality of life.

Over a 5 year period, of those patients with intermittent claudication:

a. Most will have stable claudication
b. 10-20% develop worsening symptoms
c. 5-10% develop critical limb ischaemia
d. Amputation is eventually required 1-2%
COMPLICATION
Two years following a below-knee for chronic limb ischaemia:
a. 15% require a further above knee amputation
b. 30% have died
c. 40% have full mobility

The 5 year mortality rate in those diagnosed with chronic limb

ischaemia is around 50%
SUMMARY

 Chornic limb ischaemia is a common condition, ranging in severity across the

population, associated with several cardiovascular risk factors
 Whilst a clinical dianosis, it can be quatnified by ABPI testing, following by angiogram
imaging
 Surgical intervention can be offered if conservative management options fail or those
presenting with critical limb ischaemia
 The 5 year mortality rate in those diagnosed with chronic limb ischaemia is around 50%