ABC of Vascular Disease

Critical Limb Ischaemia

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1. What is critical limb ischaemia?
Critical limb ischaemia (CLI) is a severe form of occlusive arterial disease.  There is reduction of blood flow to parts of the limb to such an extent that these parts of the limb are at risk of developing gangrene.  CLI is associated with severe pain at rest which is often worse at night and there may also be ulcers on the leg and foot.

2. What causes critical limb ischaemia (CLI)?
Critical limb ischaemia is a severe form of occlusive arterial disease where there are blocked arteries at more than one point in the leg.  Most patients with CLI have a long history or worsening arterial disease, often for many years, and may have had previous investigations and operations.  Only a small proportion of patients with intermittent claudication will develop CLI, particularly if the risk factors are treated early.

3. What do I do if I think I have CLI?
CLI is a serious condition and the first thing is to see your GP urgently.  Your GP will probably refer you to a vascular surgeon for urgent investigation, advice and treatment.

4. How can CLI be treated?
As with all occlusive arterial disease it is important to identify and treat any risk factors that may be accelerating or aggravating the condition.  In CLI the collateral arteries have reached the limit of their ability to compensate and spontaneous improvement is unlikely.  CLI is strongly associated with arterial disease elsewhere, particularly in the heart, and this increases the risk of serious complications.  In general, unless some action is taken, a patient with CLI has a significant chance of developing gangrene in the affected leg and requiring an amputation.  The most effective treatment is an operation to bypass the blocked arteries and to restore a good blood flow to the leg and foot.  This is a major operation and can only be offered if the patient is well enough to undergo an anaesthetic.  Occasionally it is possible to do a lesser operation which does not completely relieve all the occlusions but improves the blood supply sufficiently to relieve the worst symptoms and avoid an amputation.  In some cases it is possible to improve the blood supply by angioplasty.  In order to decide which form of treatment is possible your vascular  will need to get an x-ray of the arteries (angiogram).  With this information your vascular surgeon can discuss the possible treatment options.

Only a few patients are unsuitable for a bypass operation or angioplasty, and in for these unfortunate cases the treatment options are limited.  There are no drugs or other treatments that have been shown to be very effective.  Often strong pain killers are the only option to control the symptoms.

If the pain is uncontrollable or gangrene and infection become established then an amputation may be necessary as a life protecting operation because without it there is a risk of the infection spreading and causing blood poisoning.

5. What if I need an amputation?
Amputation is always the last option but occasionally it is the only one.  Amputation operations are done to remove as little of the leg as possible to allow optimum mobility afterwards.  If possible the amputation is done below the knee because this preserves the knee joint which is very important for walking.  After the amputation wounds have healed a process of rehabilitation starts.  For most patients this will involve making and fitting an artificial leg and learning how to walk with it.  Many patients achieve better pain-free mobility afterwards than they had when their leg was critically ischaemic.

S.R.Dodds 2006

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