1. CRITICAL LIMB ISCHEMIA Definition and Workup Presented by; Sultan Al Sheikh

2. Definition Inadequate arterial blood flow to accommodate the metabolic needs of resting tissue Two important variables: 1. clinical symptoms 2. measured circulatory impairment impairment

3. Definition TASC definition: persistent, recurring ischemic rest pain requiring opiate analgesia for at least 2 wk persistent, recurring ischemic rest pain requiring opiate analgesia for at least 2 wk ulceration or gangrene of the foot or toes, and ankle systolic pressure less than ulceration or gangrene of the foot or toes, and ankle systolic pressure less than 50 mmHg or toe systolic pressure less than 30 mmHg ( or absent pedal pulses in patients with DM) 50 mmHg or toe systolic pressure less than 30 mmHg ( or absent pedal pulses in patients with DM)

4. CLI Mortality rate : claudication is 50% at 5y claudication is 50% at 5y CLI 70% at 7y and 85% at 10y CLI 70% at 7y and 85% at 10y

5. classification Traditional Fontaine classification system: I Asymptomatic I Asymptomatic II Claudication II Claudication III Ischemic rest pain III Ischemic rest pain IV Ischemic ulceration/necrosis IV Ischemic ulceration/necrosis

6. CLI Fontaine stage III & IV: rest pain rest pain pedal necrosis : ischemic ulceration or pedal necrosis : ischemic ulceration or necrosis necrosis Documentation of circulatory impairment

7. CLI Circulatory impairment ( TASC ) : 1. ankle pressure less than 50 to 70 mmHg 2. Toe pressure less than 30 to 50 mmHg 3. Transcutaneuos partial pressure of oxygen at the foot is less than 30 to 50 mmHg 50 mmHg

8. CLI CLI can progresses directly from fontaine I to stage III & IV Dormandy ( multicenteric) : 50% were asymptomatic 6 m before 50% were asymptomatic 6 m before major amputation for CLI major amputation for CLI In general CLI inevitably progress to limb In general CLI inevitably progress to limb loss without revascularisation loss without revascularisation

9. CLI At least 2 or more levels of severe arterial occlusion. Usually fempop or infrapop occlusion ( adjacent vascular bed ) or superficial femoral and deep fem (parallel beds)

10. ATHEROSCLEROSIS Age Male gender DMSmokinghypertentionHyperlipidemiaHyperfibrinogenemiaHyperhomocysteinemiahypercoagulability

11. Rest Pain DefinitionAgeSexSymptoms H/O claudication Previos History Family History

12. Rest Pain General appearance Local exam: horizontal------- pale,guttered veins horizontal------- pale,guttered veins dependent------deep reddish-purple dependent------deep reddish-purple pressure areas pressure areas temp. capillary refilling. Pulses temp. capillary refilling. Pulses auscultation auscultation

13. Gangrene Dead tissue Line of demarcation Infected ( wet gangrene) Non-infected ( dry gangrene )

15. Ulceration Causes: large-artery obliteration: atherosclerosis, embolism. large-artery obliteration: atherosclerosis, embolism. small-artery obliteration: raynauds diseas, scleroderma, Buergers disease,embolism, radiation, electric burn. small-artery obliteration: raynauds diseas, scleroderma, Buergers disease,embolism, radiation, electric burn.

16. Ulceration PositionTendernessTemperatureSizeEdgesBaseDepthDischarge Relations:bare bone or tendon at the base

18. Cardiac and cerebrovascular evaluation Systemic nature of atherosclerosis must be assessed in all pt with new onset PAD Duplex for carotids ( 28% significant stenosis in pt with infrainguinal bypass)

19. Clinical predictors of increased CV risk: MI,HF,death MAJOR 1. Unstble coronary syndrome 2. Decompensated HF 3. Significant arrhythmias 4. Severe valvular disease Intermediate 1. Mild angina 2. Previous MI 3. Compensated HF 4. DM 5. Renal insufficiecy

20. Clinical predictors of increased CV risk: MI,HF,death Minor 1. Advanced age 2. Abnormal ECG (LT vent. Hypertrophy, LBBB) 3. Rhythm other than sinus 4. Low functional capacity 5. H/O stroke 6. Uncontrolled HTN

21. Evaluation Surgical or percutaneous intervention: symptoms symptoms co-morbidity co-morbidity location location severity severity

22. Evaluation Segmental arterial pressure and ABI presence presence location location supranormal ABI supranormal ABI correlate with pulse volume recording and toe pressure correlate with pulse volume recording and toe pressure little benefit in planning intervention little benefit in planning intervention

23. Exercise test In pt palpable pulses but disabling symptoms ankle pressure at rest ankle pressure at rest treadmill at 3.5 km/h treadmill at 3.5 km/h measure again measure again

24. Duplex imaging Non invasive, low cost, operator dependent Delineate arterial anatomy and blood flow Aly and colleage ( 90 pts) sens. 92% and spec. 99% for occlusion sens. 92% and spec. 99% for occlusion sens 89% and spec 98% for lesion length sens 89% and spec 98% for lesion length

25. Contrast intra arterial subtraction angio Most commonly used for planning intervention Complete visualzation Risks: reaction 0.1% reaction 0.1% mortality 0.16% mortality 0.16%

26. Complications of angiography Puncture site hemorrhage/hematoma hemorrhage/hematoma pseudoaneeurysm pseudoaneeurysm arteriovenous fistula arteriovenous fistula atherembolization atherembolization local thrombosis local thrombosis

27. Complications of angiography Contrast related major sensitivity reaction ( anaphylactoid) major sensitivity reaction ( anaphylactoid) minor reaction minor reaction vasodilation / hypotesion vasodilation / hypotesion nephrotoxicity nephrotoxicity hypervolemia ( osmotic ) hypervolemia ( osmotic )

28. MRI Gadolinium enhanced Entire arterial tree, including pedal vessels Superior for patent distal vessels Difficulties: metallic implants metallic implants claustrophobia claustrophobia gadolinium gadolinium More cost effective ( in considering angioplasty) Angiograph superior for planning surgery

29. THANK YOU