Chronic Limb Ischaemia

Question 1

What is CLI most commonly caused by?

Answer 1

Atherosclerosis in lower limbs.

Question 2

Epidemiology

Answer 2

15-20% of individuals over 70 have CLI

Increases with age

More common in males

Question 3

Risk factors

Answer 3

Smoking

DM

HTN

Hyperlipidaemia

Increasing age

FH

Obesity and physical inactivity

Question 4

Stages of CLI

Answer 4

Stage I = Asymptomatic

Stage II = Intermittent claudication

Stage III = Ischaemic rest pain

Stage IV = Ulceration or gangren or both

This is called Fontaine classification

Question 5

What is Buerger’s test

Answer 5

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

Question 6

What is Leriche syndrome?

Answer 6

A form of peripheral arterial disease affecting the aortic bifurcation

This leads to buttock or thigh pain + ED

Question 7

What is critical limb ischaemia?

Answer 7

The advanced form of CLI

Question 8

Define critical limb ischaemia

Answer 8

Ischaemic rest pain for greater than 2 weeks duration

Presence of ischaemic lesions or gangren

ABPI < 0.5

Question 9

Examination of critical limb ischaemia

Answer 9

Pale and cold

Weak or absent pulses

Hair loss

Skin changes with atrophic skin, ulceration aor gangren

Thickened nails

Question 10

Dx

Answer 10

Spinal stenosis

ALI

Question 11

Investigation

Answer 11

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.

Question 12

Explain ABPI

Answer 12

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

Question 13

Medical management

Answer 13

Lifestyle advice with smoking cessation, regular exercise and weight loss

Atorvastatin 80mg OD

Clopidogrel 75mg OD

Optimise diabetes control

Supervised exercise programme

Question 14

Indications of surgical management

Answer 14

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.

Question 15

Two main surgical approaches

Answer 15

Angioplasty +/ stenting

Bypass grafting

Combination of the two

Amputation if beyond repair

Question 16

Complications

Answer 16

Sepsis

Acute-on-chronic ischaemia

Amputation

Reduced mobility and QOL