Chronic Limb Ischemia

Julio Levi Sinaga

1807101030049

PROGRAM STUDI PROFESI DOKTER

D I V I S I B E D A H T O R A K S K A R D I A K & VA S K U L A R / K S M I L M U B E D A H
F A K U LT A S K E D O K T E R A N U N I V E R S I T A S S Y I A H K U A L A
BANDA ACEH
2020
ARTERIES OF UPPER LIMB ARTERIES OF LOWER LIMB

P rofu n da
fe rmoris

Palmar Arches
 Definisi
Chronic Limb Ischemia adalah penyakit akibat obstruksi
kronik pembuluh darah arteri pada tungkai disebabkan
terutama karena plak aterosklerosis dan selain itu dapat
juga akibat proses peradangan pembuluh darah dan
Tromboemboli (> 2 minggu)
E TIOLOGI
LOWER LIMB ISCHEMIA
 Atherosclerosis
 thrombangiitis obliterans
U P P E R LIMB ISCHEMIA
 Aorto-arteritis (Takayasu arteritis )
 Raynaud's disease
 Thoracic outlet obstruction
 Other rarer causes
mixed cryoglobulinemia,
nodular periarteritis,
dermatomyositis,
systemic scleroderma
SENILE ATHEROSCLEROSIS IS
COMMON IN
BOTH LOWER AND UPPER
LIMB
 Faktor Resiko
 Umur (>70 yrs)
 Laki Laki
 Diabetes
 Merokok
 Hipertensi
 Dislipidemia
 Hypertriglyceridemia
 Hiperhomosisteinemia
 Gaya Hidup Sedentari
 Riwayat Keluarga
 Diet Lemak Tinggi
 Obat ( beta blockers, OCP )
 ATHEROSCLEROSIS
 Merupakan kondisi inflamasi komplek kronik dari arteri yang elastis dan
muscular , dapat berupa sistemik maupun segmental
 A r t e r y y a m g s e r i ng te r k e n a a d a l a h — Aorta abdominal bagian infra renal,
arteri koroner, pembuluh darah iliofemoral, bifurkasio karotis dan popliteal.
Sangat jarang terjadi pada arteri tungkai atas , karotis, mesentrik, dan arteri
renalis

Penumpukan lemak
Brief pa t h o ph y si o l o g y
Kalsifikasi

A
r
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a

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 CH RO N IC LIMB ISC HEMIA pa
da pasien diabetes

H i gh g l u c o s e Diabetic Diabetic Glycosylated

l ev el i n t i s s u e s n eu r op a t h y m icr o a n g i op a t h y
h aemoglobin
A g o o d c ulture Loss of sensation
m e d i a for bac ter ia blockade of
ULCE R m icrocircula tion

Increased in blood
Infection causes defective oxygen
dissociation

Thrombosis can be
precipitated by Blockage occurs a t
infection causing plantar, tibial, and Hypoxia
infective gangrene . dorsalis pedis vessels

Diabetic
At he roscler osis
Limb Ischemia
 Gejala Klinis
Tandanya adalah 6 P (Pain pada saat berjalan (Intermiten claudication / Rest pain) +
Gangrene + Ulser Kecil
Boyd’s Clas sifi cati on Cl au di cat i on of Ler i ch e – F o n t a i n e cl i n i cal
Pain Clas sifi cati on
 Grade I – Stage I : asymptomatic
patient;
P a t i e n t d e v e l o p s p a i n o n wa l ki ng .
B u t if h e c o n t i n u e s t o wal k , t h e p a i n S t a g e II: i n t e r m i t t e n t claudication;
di s appears . G rade I I–
 S t a g e III: p a i n d u r i n g rest, l o w e re d i n
P a t i e n t d e v e l o p s p a i n o n wal k i n g. o rth os ta ti s m.
B u t if h e c o n t i n u e s t o wal k , t h e p a i n
persi s ts. B u t t h e p a t i e n t c a n still S t a g e IV: tro p h i c c h a n g e s
w a l k w i t h s o m e efforts. ( u l cerat i on s , g a n g re n e ) a n d

Grade I I I– p e r m a n e n t pai n .
Patient develops pain on
wal ki n g .
T he p a i n c o m p e l s t h e p a t i en t to
Rutherford classification
t a k e rest . G r a d e C l i n i c a l f e a t ur e
1 Asymptomatic
2 Mild claudication
3 Moderate claudication
4Severe claudication
4 Ischaemic rest pain
5 Minor tissue loss
6 Major tissue loss
Level of Claudication according to the site of
obstruction
Obstruction level Pain upto

Aorta or Buttock, hip

iliac artery(30%)
Femoral artery Thigh,
or branches(60%) upper2/3rd
calf

Popliteal artery lower

1/3rdCa
lf,
Tibial & Ankel & foot
dorsalis pedis artery
 Elevated a r m stress test (EAST)
Adson’s test (Scalene manoeuvre) modified Roos test Allen’s t e s t

Hyp e r a bd uc ti o n m a n o e u v re (Wri ght test) Costoclavicular compression manoeuvre

(Falconer test):
 Pemeriksaan Penunjang

Ankle Brachial Index

Harkin DW, Dunlop DM. Vascular trauma. Surg (United Kingdom) [Internet]. 2018;36(6):306–13. Available from: https://doi.org/10.1016/j.mpsur.2018.03.008
 Pemeriksaan Penunjang

Angiografi

USG Duplex
• .

Harkin DW, Dunlop DM. Vascular trauma. Surg (United Kingdom) [Internet]. 2018;36(6):306–13. Available from: https://doi.org/10.1016/j.mpsur.2018.03.008
TREATMEN T
 Life style modification
St op s m o k i n g
Supervised exercise
Regular walk
F a t free diet
Weight reduction
limb care
foot cleaning Strict control of
Application of Blood
mousteriser pressure
Blood sugar
Cholesterol

Avoid pre c i pi ta ti ng factors— Cold/ Dr ug s

 MEDICAL TREATMENT
 Vasodialators – Nifedipine
Xanthinol nicotinate
 Pentoxifylin 400 mg TDS PO
D e c re a s e s blood visc oc ity
I nc re a se s flexibity of
RBC
 Anti-Plateletes Drugs
Low dose Aspr in 75 mg OD
PO
Clopidogrel 75 mg OD
PO Cilastazole - 100 mg BD
 PO
Hypolipidimics - Atrovastatin 10- 40 mg OD PO
 ANALGESICS
Indi cati ons :
claudication interfering with lifestyle
critical limb ischemia

 Angioplasty : Conven t ional

Sub- intimal

 End artrectomy : Open

Semiclosed
Weily
 Stenting eversion
technique
Arterial bypass
Insitu sephanous
Graft : Nat ural :
Reverse sephanous
Artificial : Anatomical
Extra Anatomical
 Amputation :
SUMMARY OF PREFERRED OPTIONS
 PERCUTANEOUS TRANSLUMINAL
BALLOON ANGIOPLASTY (PTA):
 It is useful in cases of localised stenosed areas.
 Through t ra ns femoral Seldinger approach, initially angiogram is done.
Then under guidance (fluoroscopic) stenosed area is approached.

 Balloon of the angioplasty catheter is inflated a t stenosed area for one

minute and repeated if required. Plaques should rupture. Catheter is
withdrawn.
 ENDARTERECTOMY

 F or focal/ i sol a te d bl oc k
 It is removal of thrombus
along with diseased intima

through a n arteriotomy.
Endothelium of the vessel
is removed, hence the
name.

There are three methods—

(1) Open method
(2) Semi-closed
(3) Wiley’s eversion endarterectomy

Advantages are—it avoids prosthetic graft and its

co mplic at ions —re occ lusion a n d restenosis.

 P ROF U N D AP LAS
TY:

 localised block in opening of

profunda femoris (deep femoral).

Profunda femoris is opened,

thrombus if present, is removed.
 Opening is widened using
either venous or synthetic
(Dacron or PTFE) grafts.
 ARTERIAL/VENOUS GRAFTS:

S yn th et i c
 Dacron woven /knitted graft

 Dacron coated

 PTFE—

N apolytetrafluoroethylene
tural
 graft
Long saphenous vein either reverse or in situ
 Umbilical vein graft (cryopreserved)—3 m m

vein is the minimum diameter required

 REVERSE S A P H E N O U S VEIN GRAFT
A d v a n t a g e s over s y nt he ti c g r a f t
 Better patency rate ( 5 yr rate : 60% compared to 50% of synthetic graft )
 Less prone to thrombus
 Lesser tendency to dilate

Disadvantage :
High skill required
More morbid procedure
 Early Graft Necrosis ( rare now )
 ANATOMICAL BYPASS
Aortofemoral
C o m pl ic a t i o n
Hemorrhage
Femor opoplitea l Adjacent organ damage Autonomic nerve damage
Poplitealtibial Cardiac/Renal/Respiratory Failure
Colonic/ pelvic ischemia
Aorto-enteric Fistula

Femoro-popliteal bypass graft Aortofemoral bypass graft

 EXTRA-ANATOMIC BYPASS

 Axillofemoral
 Axillobifemoral bypass
 Femoral-Femoral bypass
Indic a ti on s :
1.Difficulty in Abdominal /
retroperitoneal access
2.Abdominal infection/malignancy
3.Pt . Unfit for major vascular
surgery

Axillofemor a l bypa ss Axillobifemoral bypass

 O MEN TO P LAS
TY
 It promotes ulcer healing, reduces the pain and controls
the features of ischaemia.

It can also be used in upper limb ischaemia.

If patient continues to smoke, disease spreads to these
omental vessels also.

C o m p l i c a t i o n s of omentoplasty:

1. Abdominal sepsis.
2. Incisional hernia,
3. Adhesions and intestinal obstruction.
 A MPUTATIONS
 Indications- Evaluation of the Patients who need Amputation
Ga n gren ou s 1. Haematocrit,
Non 2.control of anaemia by transfusing blood/ packed
salvageable cells.
limb 3.Control of infection using antibiotics.
4.Decision of level of amputation by skin
temperature, arterial Doppler.
5.Informed consent should be taken.
6.Plan for prosthesis and
rehabilitation by
physiotherapist and rehabilitation
team.
Thankyou so much for your attention….