PERIPHERAL

ARTERY DISEASE
ACUTE LIMB
ISCHEMIA
 ACUTE LIMB ISCHEMIA
Acute Limb Ischemia (ALI) defined as sudden decrease in
arterial blood flow to limb that threatens its viability, that is
present within 2 weeks.

It is a vascular emergency and can lead to extensive tissue

necrosis, which may ultimately result in limb amputation or
even death.
 ETIOLOGY
1) Thrombosis (80-85%)
• most commonly due to plaque rupture in an atherosclerotic segment
(thrombosis in situ) in patients with PAD.
• Thrombus may also form in context of thrombophilia, malignancy,
hypovolaemia.

2) Embolism (10-15%)
• Arises from a thrombus in the left atrium (in association with atrial
fibrillation) or mural thrombus (following myocardial infarction).
• Other sources include: Heart prostheses or bypass graft, and aneurysms.
3) Trauma
• Can be result of iatrogenic injury during interventional procedures,
such as percutaneous coronary intervention.
• Fracture or diclocation- cause intimal injury to vessels.
RISK FACTORS
 HISTORY
Typical symptoms:
• Pain in affected limb usually at rest
• Discoloration
• Altered sensation (paraesthesia)
• Paralysis in affected limb (late sign)

Also important areas to cover in history include:

• Past medical history/comorbidities
• Predisposing risk factors
CLINICAL PRESENTATIONS (6Ps)
 CLINICAL EXAMINATIONS
INSPECTION:
1. Colour of lower limb

2. Trophic changes :
-loss of hair, nail thickening, dry shiny skin,
small non- healing sores/ulcers.

3. Presence of ulcer

4. Presence of gangrene
wet gangrene - has ill defined spreading edge
dry gangrene - well defined edge - auto amputation may occur
PALPATION :
1. Temperature
2. Capillary Refill Time (<2s)
3. Palpate peripheral pulses
4. Sensation / paraesthesia

MOVEMENT
weakness / paralysis
Most common findings :
• Marble white apprearance of skin
• Absent limb pulses on palpation
• Cold limb

Less common findings usually appear in later stages :

• Paraesthesia (with reduced or complete loss of light touch sensation in distal limb)
• Paralysis (inability to move toe or fingers)
• Muscle weakness
• Gangrene
 EMBOLIC vs THOMBOTIC
Clinical features Thrombus Embolus

Onset Gradual, vague Sudden

Severity Less severe Severe

Peripheral arterial disease History of PAD symptoms Unlikely

Previous vascular surgery/ Likely Unlikely

endovascular interventions
Cardiac history Unlikely History of AF, recent MI
 Clinical features Thrombus Embolus
Appearance and feel Less cold, cyanotic Cold, mottled

Palpation of artery Hard, calcified Soft, tender

Contralateral leg pulses Absent Present

RUTHERFORD CLASSIFICATION
 INVESTIGATIONS
Bedside investigations
• Duplex ultrasound/Doppler scan : to confirm abscence of pulses
• ECG : to look for atrial fibriallation of ischemic changes

Laboratary investigations
• Baseline blood tests -FBC, RP, electrolytes , LFT, coagulation profile
• Serum lactate : to assess severity of ischaemia.
• Thrombophilia screen (if no known risk factor)
• GSH/GXM if patient may require emergency surgical intervention.
Imaging
• CT/MR angiography: to guide
revascularisation if limb is viable
• Echocardiography if an embolus
of cardiac origin is suspected
MANAGEMENT OF ALI
 INITIAL MANAGEMENT OF ALI
• IV Heparin
- to prevent clot propagation + maintain collateral vessels
- bolus dose of 5000 units, followed by continuous infusion of 15-25
units/kg/hr
- 6 hourly coagulation profile and dose adjustment)
- keep aPTT ratio 2-3

• Adequate analgesia
 Acute Limb Ischemia
↓
Resuscitation, heparin and pain management

↓ ↓ ↓
viable, no neurological viable,with neurological Irreversible
deficit (Rutherford I) deficit (Rutherford II) (Rutherford III)
↓ ↓ ↓

Initial work-up Urgent revascularisation

Amputation
DUS, CTA, DSA thrombectomy/ bypass
↓ ↓
Revascularisation Underlying vascular
within hour lesion?
(thrombolysis/ ↓ ↓
thrombectomy/
bypass) Present Absent
↓ ↓
Endovascular therapy Medical therapy and
and/or surgery follow up
↓
• For marginally or immediately threatened limbs (Category IIa and IIb),
revascularisation should be performed emergently within 6 hours.

• For viable limbs (Category I), revascularisation should be performed

on urgent basis within 6-24hours.
 SURGICAL TREATMENT OF ALI
Surgical Embolectomy
• Rapid revascularization
• Can be done via low tech
instrument
• Trasfemoral approach can be
done via local anaesthesia
Catheter Directed Thrombolysis
- Direct delivery of the drug into existing
thrombus
- Less thrombolytic drug dosage
- Less systemic bleeding complications
- Lyses clot in both large and small vessels
- Lower reperfusion syndrome than
embolectomy
- Done via percutaneous approach with
local anaesthesia
 Contraindications to thrombolytic agents
Absolute Contraindications Relative contraindications

• Active bleeding disorder • Major surgery o trauma

• Gastrointestinal bleeding
within 10 days
• Cerebrovascular event
within 6 months
• Intracranial or spinal
surgery within 3 months
• Head injury within 3
months
within 10 days
• CPR within 1o days
• Pregnancy
• Hepatuc failure
• Intracranial tumour
Arterial Bypass Surgery
Amputation

• Performed in a non-salvageable (class III) limb

 COMPLICATIONS
Surgical revascularisation causes sudden reperfusion of ischaemic tissue in
the affected limb, which can, in turn, lead to reperfusion injury. This can
consist of:
• Massive oedema: resulting in compartment syndrome and hypovolaemic shock.
The sudden release of built-up substances which can lead to various systemic
complications:
• Hyperkalaemia due to the release of K+ ions: can cause cardiac arrhythmias.
• Systemic acidosis from the release of H+ ions.
• Acute kidney injury due to the release of myoglobin: patients may require
emergency renal replacement therapy.
Other important complications to remember include:

• Compartment syndrome due to oedema formation on reperfusion of

the limb and confinement of the muscles in their tight fascia: can
ultimately lead to muscle necrosis and is an emergency.
• Peripheral nerve injury, which can lead to chronic severe neuropathic
pain in the limb.
• The psychosocial impact of limb amputation on the patient and
associated physical morbidity (e.g. stump or phantom limb pain,
immobility, etc).
LONG TERM MANAGEMENT OF ALI
• Smoking cessation
• Diet and exercise
• Statin therapy and managing cholesterol
• Preventing, diagnosing, and managing diabetes
• Preventing, diagnosing, and managing hypertension
• Antiplatelet therapy
CHRONIC LIMB
ISCHEMIA
. Chronic limb
ischemia

Non Critical:
Critical
Intermittent claudication
 ETIOLOGY
1. Atherosclerosis: (most common)
• Hypertension
• Hyperlipidemia
• Diabetes mellitus

2. Non-atherosclerosis:
• Buerger’s disease (aka thromboangitis obliterans)
• Vasculitis
• Vasospasm
CLASSIFICATION
1. FONTAINE CLASSIFICATION
• The first classification system emerged from the European Society of Cardiovascular Surgery and
was published in 1954
• The system is solely based on clinical symptoms, without other diagnostic tests, and is typically
used for clinical research and not routinely used in patient care
2. Rutherford classification
 NON CRITICAL LIMB ISCHEMIA
WITH CLAUDICATION
Intermittent claudication is defined as a reproducible discomfort of a
defined group of muscles that is induced by exercise and relieved with rest

• Muscular pain
• Not present at rest
• Comes on walking at a particular distance (claudication distance)
• Quickly relieved by resting
• Repetitive
Types of claudication:

1. Calf claudication - Usually affects the superficial femoral near to the adductor
hiatus, or the popliteal artery
2. Foot claudication - tibial and peroneal arterial disease, but rarely do patients
with claudication due to atherosclerosis get foot pain alone (more common in
Buerger‘s)
3. Thigh claudication - common femoral artery or aortoiliac disease

* LeRiche’s syndrome arises from occlusion of the aortoiliacs, and is composed

of a classical tetrad of buttock claudication, impotence in men, absent femoral
pulses (and distal pulses), and occasionally presence of aortoiliac bruits.
VASCULAR VS NEUROGENIC
CLAUDICATION
 CRITICAL LIMB ISCHEMIA
• Defined as decrease in limb perfusion that causes a potential
threat to limb viability (manifested by ischemic rest pain,
ischemic ulcers, and/or gangrene) in patients who present
after more than two weeks
CLINICAL FEATURES
1. Rest pain requiring regular analgesia lasting >2 weeks AND/OR
2. Gangrene or ulcers over the toes or feet AND
3. Objective indication of poor vascular supply to the lower limbs
(a) Ankle brachial pressure index <0.4
(b) Toe pressure <30mmHg
(c) Ankle pressure <50mmHg
ABPI measurement:
• 2 things: hand held doppler probe and BP cuff
• Cuff is inflated until the pulse distal to the cuff is no longer heard by doppler
• The cuff then slowly deflated until the pulse is again detected
• This measurement is recorded as SBP

ABPI= SBP of DPA or PTA/ SBP of Brachial artery

Rest pain
• Severe pain in the distal portion of the lower limb
• (usually toes, foot but may involve more proximal areas if disease is severe)
occurring at rest
• Aggravated or precipitated by lifting the limb
• Relieved by dependency of the limb
• many patients sleep with the leg hanging over the side of the bed to relieve the
pain
• Disturb sleep at night
• Not easily controllable with analgesia
• requires opioids to control pain
• If persist more than 4-8 weeks, may require operative intervention
Ischaemic ulcers (most are neuroartheropathic ulcers)
• Usually arise from minor traumatic wounds with poor healing
• Often painful
• Most often occur on the tips of the toes, bunion area, over the
metatarsal heads (ball of the foot), lateral malleolus (as opposed
to venous ulcers that occur over the medial malleolus)
• Usually deep, dry, punctate
• (unlike venous ulcers that tend to be superficial, moist, diffuse)
• May become infected resulting in cellulitis, even abscess
formation, and spread to involve the underlying bone and joints -
osteomyelitis, septic arthritis
Gangrene
• Occurs when arterial blood supply falls below that which is necessary to
meet minimal metabolic requirements (progression to necrosis)
 INVESTIGATIONS
1. Laboratory : FBC, RP, PT/PTT, septic workup: blood c/s, wound c/s
2. Ankle-brachial pressure index
Interpreting the values :
- Normal ABPI is > 0.9 (can be more than 1.0 as ankle pressures tend to be
higher than brachial; if >1.3, suggests non-compressible calcified vessel)
- ABPI between 0.5 - 0.9 – occlusion, often associated with claudication
- ABPI < 0.5 : critical ischemia rest pain
3. Arterial Duplex ultrasound
4. Angiogram (arteriogram)
- Usually only done if planning intervention e.g. angioplasty, stenting
 MANAGEMENT
MANAGEMENT OF INTERMITTENT CLAUDICATION:
1. Best medical therapy (BMT)- risk factor modification
• Stop smoking
• Hypertension, hypecholestrolemia, obesity control
• Antiplatelet agent
• Exercise therapy
• Diabetes identification and active treatment
• Foot care
2. Surgical/ endovascular intervention
EXERCISE THERAPY
• Aim : Improves symptoms and quality of life and increases maximal walking
distance
• Did not improve ABI
• Supervised more effective than non-supervised
• Impossible in patient with CLI but can be considered after successful
revascularization
• Alternative exercise mode : cycling, strength training, upper-arm ergometry
PHARMACOTHERAPY
Aim : to decrease walking impairment
1. Cilostazol :
• Inhibitor of phosphodiesterase type III
2. Naftidrofuryl oxalate:
• Vasodilator agent with an antagonist effect on 5-HT2 receptors of
the smooth muscle cells. 
3. Prostanoids, pentoxifylline, L-arginine, buflomedil, antihypertensive
e.g. verapamil), statins, antiplatelet agents
REVASCULARIATION
1. Aorto-iliac lesion
• Short stenosis/occlusion <5cm of iliac arteries : endovascular therapy
• Ileofemoral lesion : hybrid procedure (endarterectomy or bypass at femoral
level combined with endovascular therapy of iliac arteries)
• Extends to infrarenal aorta : covered endovascular reconstruction of an aortic
bifurcation
• Occlusion comprises the aorta up to renal arteries and iliac arteries :
aortobifemoral bypass surgery (in fit patient with severe life-limiting
claudication)
• If no any other alternative : extra-anotomic bypasss (e.g. axillary to femoral
bypass)
2. Femoropopliteal lesion
• If circulation to profunda femoral artery normal : exercise therapy
• Stenosis/occlusion <25cm : endovascular therapy
• Stenosis/occlusion >25cm : endovascular recanalization is possible
but long-term patency achieved by surgical bypass
B. MANAGEMENT OF CRITICAL LIMB ISCHEMIA

1. Revascularization
2. Amputation
3. Spinal cord stimulation
4. Stem cell and gene therapy
REVASCULARIZATION
1. Aorto-iliac disease
• Hybrid procedures (e.g. aorto-iliac stenting and distal bypass)
2. Femoropopliteal disease
• CLI unlikely to be related to isolated femoral artery lesions (usually
femoropopliteal with aorto-iliace or below the knee disease are found )
• If endovascular therapy is the choice - landing zones for bypass should be
preserve
• If bypass is decided – should be short as possible using saphenous vein
3. Infrapopliteal disease
• Stenotic lession and short occlusions : endovascular therapy
• Long occlusions of crural arteries : bypass with an autologous vein
AMPUTATION
1. Minor amputation
• Often necessary to remove necrotic tissues
• Revascularization is needed before amputation to improve wound healing
• Foot TcPO2 and toe pressure can be useful to delineate the amputation zone
2. Major amputation
• For extensive necrosis or infectious gangrene and non ambulatory with severe
co-morbidities
• Secondary amputation : should be performed when revascularization has failed
and reintervention is no longer possible or limb continues to deteroriate
• Bedridden : femoral amputation may be the best option