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    Chronic Limb Ischaemia: MR Hanif Hussein Consultant Vascular Surgeon, HKL

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    Zulzaire Zulkefli
    This document discusses chronic limb ischaemia, which is inadequate blood flow to the limbs caused by narrowing of the blood vessels. It presents risk factors like smoking and outlines symptoms ranging from intermittent claudication to critical limb ischaemia with rest pain or tissue loss. Diagnosis involves physical exams of pulses and imaging of blockages. Treatment is multi-disciplinary and can include modifying risk factors, medications, endovascular procedures like angioplasty, open bypass surgery, wound care, amputation in some cases, and rehabilitation. The key messages are early diagnosis, examining pulses, early specialist referral, and prioritizing life over the affected limb.

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    Chronic Limb Ischaemia: MR Hanif Hussein Consultant Vascular Surgeon, HKL

    Uploaded by

    Zulzaire Zulkefli
    116 views35 pages
    This document discusses chronic limb ischaemia, which is inadequate blood flow to the limbs caused by narrowing of the blood vessels. It presents risk factors like smoking and outlines symptoms ranging from intermittent claudication to critical limb ischaemia with rest pain or tissue loss. Diagnosis involves physical exams of pulses and imaging of blockages. Treatment is multi-disciplinary and can include modifying risk factors, medications, endovascular procedures like angioplasty, open bypass surgery, wound care, amputation in some cases, and rehabilitation. The key messages are early diagnosis, examining pulses, early specialist referral, and prioritizing life over the affected limb.

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    Chronic_Limb_Ischaemia

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    This document discusses chronic limb ischaemia, which is inadequate blood flow to the limbs caused by narrowing of the blood vessels. It presents risk factors like smoking and outlines symptoms ranging from intermittent claudication to critical limb ischaemia with rest pain or tissue loss. Diagnosis involves physical exams of pulses and imaging of blockages. Treatment is multi-disciplinary and can include modifying risk factors, medications, endovascular procedures like angioplasty, open bypass surgery, wound care, amputation in some cases, and rehabilitation. The key messages are early diagnosis, examining pulses, early specialist referral, and prioritizing life over the affected limb.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    116 views35 pages

    Chronic Limb Ischaemia: MR Hanif Hussein Consultant Vascular Surgeon, HKL

    Uploaded by

    Zulzaire Zulkefli
    This document discusses chronic limb ischaemia, which is inadequate blood flow to the limbs caused by narrowing of the blood vessels. It presents risk factors like smoking and outlines symptoms ranging from intermittent claudication to critical limb ischaemia with rest pain or tissue loss. Diagnosis involves physical exams of pulses and imaging of blockages. Treatment is multi-disciplinary and can include modifying risk factors, medications, endovascular procedures like angioplasty, open bypass surgery, wound care, amputation in some cases, and rehabilitation. The key messages are early diagnosis, examining pulses, early specialist referral, and prioritizing life over the affected limb.

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    of 35

    CHRONIC LIMB

    ISCHAEMIA
    MR HANIF HUSSEIN
    CONSULTANT VASCULAR SURGEON, HKL
    INTRODUCTION

    • Chronic Limb Ischaemia


    • Inadequate perfusion to the limbs
    • Narrowing of the blood vessels in
    the limbs
    • Peripheral Vascular Disease
    • Lower limbs > Upper limbs
    • Range of symptoms
    • Signs
    • Absent pulses
    • ABSI < 0.9
    Vascular Update 2011
    CRITICAL LIMB ISCHAEMIA

    Vascular Update 2011


    PERIPHERAL VASCULAR DISEASE

    • Risk Factors
    • Smoking
    • Metabolic syndrome
    • Diabetes mellitus
    • Dyslipidemia
    • Obesity
    • Hypertension
    • Gender
    • Male > Female
    • Age
    • 3 – 10 % of all ages
    • 15 – 20% over 70 year olds
    Vascular Update 2011
    PRESENTATION
    PERIPHERAL VASCULAR DISEASE

    • Symptoms
    • Asymptomatic
    • Early stage, mild disease

    • Symptoms related to muscle activity/exercise

    • Intermittent claudication

    • Rest pain

    • Non-healing ulcer Critical Limb


    Ischaemia
    • Gangrene

    Vascular Update 2011


    INTERMITTENT CLAUDICATION

    • Leg pain sufficient to cause one to stop walking, which is


    produced by exercise and relieved by rest, and is
    caused by arterial occlusive disease

    • Related to activity and life style

    • One of the early symptoms of PVD

    • But not necessarily early stage of disease

    Vascular Update 2011


    CRITICAL LIMB ISCHAEMIA

    • Persistent, recurring ischaemic rest pain requiring


    regular adequate analgesia for more than 2 weeks
    - “Rest pain”
    or

    • Leg ulceration or gangrene of the foot or toes -


    “Tissue loss”
    with

    • Ankle systolic pressure ≤ 50 mmHg or a toe systolic


    pressure of ≤ 30 mm Hg

    Vascular Update 2011


    CRITICAL LIMB ISCHAEMIA

    Vascular Update 2011


    MANAGEMENT
    MANAGEMENT

    • Diagnosis
    • History
    • Physical Examination
    • Bed-side non-invasive tests

    • Investigations
    • Assess lesion
    • Plans for intervention

    • Treatment
    • Risk factor modification
    • Revascularisation

    • Rehabilitation
    Vascular Update 2011
    PHYSICAL EXAMINATION

    • Examine the pulses


    • Performed in only 6-11% of leg ++ Femoral art
    examinations
    • Peripheral Pulses
    +
    • Normal Popliteal art

    • Weak
    • Absent _ _ Post tib
    Dorsalis
    pedis

    Vascular Update 2011


    PHYSICAL EXAMINATION

    • Hand-held Doppler
    • Wave forms
    Triphasic
    • ABSI
    • Ankle/Brachial systolic index
    Biphasic

    Monophasic

    Vascular Update 2011


    PHYSICAL EXAMINATION

    ABSI = Ankle SP
    Brachial SP

    Vascular Update 2011


    ANKLE BRACHIAL INDEX

    ABSI Interpretation
    > 1.1 Normal
    Hardened / Non - compressible vessels*
    0.9 – 1.1 Normal
    0.7 – 0.89 Mild to moderate disease
    (Asymptomatic to mild)
    < 0.7 Moderate to severe disease
    < 0.3 Critical limb ischaemia

    *Calcified arteries in diabetics

    Vascular Update 2011


    NON-INVASIVE INVESTIGATION

    • Toe pressure examination


    • Photo plethysmography
    • Distal perfusion in diabetic patients

    Vascular Update 2011


    INVESTIGATIONS

    • Blood
    • Full blood count
    • Infection
    • Polycythemia
    • Blood sugars
    • Lipid profile
    • Renal profile
    • Wound swab
    • Cultures and sensitivity
    • Imaging
    • Foot X-Ray – Osteomyelitis
    • MRI Foot – Soft tissue infection, OM

    Vascular Update 2011


    INVESTIGATIONS

    • Imaging

    • Level of stenosis/occlusion
    • Distal run-off

    • Plans for intervention


    • Endovascular
    • Open surgery

    Vascular Update 2011


    INVESTIGATIONS

    • Imaging options
    • Duplex scan
    • CT angiography
    • MRA
    • DS angiography

    Vascular Update 2011


    TREATMENT
    TREATMENT

    • Multi-disciplinary team approach


    • Physicians
    • Vascular surgeons
    • Interventional radiologist
    • Orthopedic surgeons
    • Plastic surgeons
    • Dietician
    • Physiotherapist
    • Occupational therapist
    • Podiatrists

    Vascular Update 2011


    INTERMITTENT CLAUDICATION

    • Conservative treatment

    • Non-debilitating claudication
    • Not affecting life style
    • Not affecting mobility
    • Not affecting daily activity/work

    • 3 – monthly reviews
    • Monitor improvement/worsening of symptoms
    • Monitor co-morbid factors
    • Continuation of pharmacotherapy

    Vascular Update 2011


    CHRONIC LIMB ISCHAEMIA

    • Treatment
    • Risk factor modification
    • Stop smoking
    • Diabetic control

    • Anti-platelet therapy
    • Lipid lowering agents

    • Exercise programmes
    • 30 – 60 minutes, 3 x / week, 3 months

    • Pain relief – anaelgesia


    • Opiods
    • Cox-2 inhibitors
    • NSAIDS
    Vascular Update 2011
    CHRONIC LIMB ISCHAEMIA

    • Indications for intervention


    • Debilitating claudication
    • Affecting lifestyle
    • Limits mobility/activity
    • Affects work
    • Critical limb iscahemia

    • Options for intervention


    • Endovascular
    • Angioplasty +/- stenting
    • Open bypass surgery
    • Hybrid
    Vascular Update 2011
    ANGIOPLASTY

    • Indications
    • Short segment lesions
    • Patients not suitable for
    bypass
    • Age
    • Co-morbid conditions

    • With/without stenting

    Vascular Update 2011


    BYPASS SURGERY

    • Indications
    • Long segment stenosis
    • Lesions at origin
    • Configurations
    • Aorto-bifemoral
    • Ilio-femoral
    • Femoro-popliteal
    • Distal bypass
    • Posterior tibia, anterior tibial, peroneal

    Vascular Update 2011


    BYPASS SURGERY

    • Reverse vein graft


    • Better patency
    • Less complication
    • Natural conduit
    • Less severe symptoms if thrombosed
    • Limited

    • Prosthetic graft (PTFE)


    • Comparable patency for proximal lesions
    • Complication
    • Graft infection
    • Severe symptoms if occluded

    Vascular Update 2011


    LOCAL WOUND TREATMENT

    • Debridement / desloughing

    • Wound care and dressing

    • Minor amputation
    • Eliminate necrotic tissue

    • Reduce septic focus

    • Promote granulation tissue

    Vascular Update 2011


    AMPUTATION

    • Primary amputation
    • Consider in selected cases
    • Non-salvageable foot
    • Poor revascularisation outcome
    • Poor distal run-off
    • Severe generalised, calcified vessel
    • Patient selection
    • Poor cardiac function
    • Poor pre-morbid condition

    • Not a failure of treatment


    • Aim – to regain mobility Vascular Update 2011
    REHABILITATION & FOLLOW-UP

    • Rehabilitation
    • Mobilisation
    • Prosthesis
    • Foot wear

    • Follow-up
    • Control of risk factors
    • Continuation of medications
    • Surveillance
    • Recurrent stenosis
    • Failing bypass grafts

    Vascular Update 2011


    TAKE HOME MESSAGE

    CHRONIC LIMB ISCHAEMIA:

    • Early diagnosis

    • Examine pulses

    • Early referral

    • Life before limb

    Vascular Update 2011


    THANK YOU
    www.hklvascular.com

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