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The leg ischemia is of two types they are : |
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- Acute leg ischemia
- Critical limb ischemia (CLI)
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Acute limb ischemia is defined as a sudden decrease in limb perfusion that threatens the viability of the limb.Critical limb ischemia (CLI) is the most severe form of peripheral arterial disease (PAD) caused by chronic inflammatory processes associated with atherosclerosis that result in markedly reduced blood flow to the legs, feet and hands. |
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Ischemia is a reduction in blood supply. The reduced blood flow in CLI is caused by arterial plaque (deposits of fatty material), which reduces the blood flow to the peripheral (outer) part of the body (i.e. legs, feet and hands). CLI is a chronic condition that results in severe pain in the feet or toes, even while resting. Complications of poor circulation can include sores and wounds that won't heal in the legs and feet. Left untreated, the complications of CLI will result in amputation of the affected limb. The condition occurs in slightly more men than women. Diabetes, abnormal cholesterol levels, chest pain, obesity and increased age are all associated with an increased incidence of CLI.
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| Symptoms |
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The primary symptom of limb ischemia is called ischemic rest pain - severe pain in the legs and feet while a person is not moving. Ischemic rest pain is typically described as a burning pain in the arch or distal foot that occurs while the patient is recumbent but is relieved when the patient returns to a position in which the feet are dependent. |
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- Pain or numbness in the feet or toes
- Open sores, skin infections or ulcers that will not heal
- Dry gangrene (dry, black skin) of the legs or feet.
- Shiny, smooth, dry skin of the legs or feet
- Thickening of the toenails
- Absent or diminished pulse in the legs or feet
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| Risk Factors |
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Risk factors for chronic limb ischemia are the same as those for atherosclerosis, hardening and narrowing of the arteries due to the build up of fatty deposits, called plaque. |
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Diabetes Mellitus
- Neuropathy
- Renal Failure
- Age Greater than 80 years
- Smoking
- Peripheral Arterial Disease
- Hypertension
- Hypercholesterolamia
- Infection
- High blood pressure
- Family history of atherosclerosis or claudication
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| Tests and Diagnosis |
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Diagnosing limb ischemia is usually done using noninvasive means in the Noninvasive Vascular Laboratory. Simple tests can be performed to assess the degree of arterial insufficiency. These are tests that are noninvasive and cause no discomfort to the patient. There are a number of tests to determine the exact causes and severity of CLI:
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- Magnetic Resonance Angiography (MRA) – A computer measures radiofrequency waves in a magnetic field to construct detailed images of blood vessels.
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- Computed Tomography Angiography (CTA) – Contrast dye injected in the blood vessel makes visible any blockages in an advanced x-ray image.
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- Doppler Ultrasound – Uses sound waves to painlessly measure blood flow through the vessel.
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- Auscultation: The presence of a bruit, or "whooshing" sound, in the arteries of the legs is confirmed using a stethoscope.
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- Ankle-brachial index (ABI): The systolic blood pressure in the arm is divided by the systolic pressure at the ankle.
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- CT angiography: An advanced X-ray procedure that uses a computer to generate three-dimensional images.
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- Angiogram: An X-ray study of the blood vessels is taken using contrast dyes.
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| Treatment |
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Diet and lifestyle: |
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- Lipid abnormalities, including elevated total and low-density lipoprotein (LDL) cholesterol, decreased high-density lipoprotein cholesterol, and hypertriglyceridemia, are strongly associated with lower-extremity PAD. As a result, low-cholesterol diets have been recommended for patients with CLI
- Cigarette smoking is a strong predictor of lower-extremity PAD, with a large number of epidemiologic studies establishing an increased incidence of PAD in smokers compared with nonsmokers.
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Interventional procedures: |
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Various endoluminal catheter-based devices have been developed for patients with CLI. These evolving technologies include balloon angioplasty, CryoPlasty therapy (Boston Scientific, Natick, MA), stent/stent-graft placement, laser atherectomy, and mechanical atherectomy. |
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Angioplasty: A tiny balloon is inserted through a puncture in the groin. The balloon is inflated one or more times, using a saline solution, to open the artery.
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Cutting balloon: A balloon imbedded with micro-blades is used to dilate the diseased area. The blades cut the surface of the plaque, reducing the force necessary to dilate the vessel.
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Cold balloon (CryoPlasty): Instead of using saline, the balloon is inflated using nitrous oxide. The gas freezes the plaque. The procedure is easier on the artery; the growth of the plaque is halted; and little scar tissue is generated.
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Stents: Metal mesh tubes that provide scaffolding are left in place after an artery has been opened using a balloon angioplasty.
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Balloon-expanded: A balloon is use to expand the stent. These stents are stronger but less flexible.
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Self-expanding: Compressed stents are delivered to the diseased site. They expand upon release. These stents are more flexible.
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Laser atherectomy: Small bits of plaque are vaporized by the tip of a laser probe.
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Directional atherectomy: A catheter with a rotating cutting blade is use to physically remove plaque from the artery, opening the flow channel.
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Surgery: |
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Arterial blockages that do not lend themselves to endoscopic procedures may warrant surgical repair, most often a bypass of the affected area.
Treatment of wounds or ulcers may require additional surgical procedures or other follow-up care. If the arterial blockages are not favorable for endovascular therapy, surgical treatment is often recommended. This typically involves bypass around the diseased segment with either a vein from the patient or a synthetic graft. Hospitalization after a bypass operation varies from a few days to more than a week. Recovery from surgery may take several weeks.
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