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Ask The Doctors: Critical Limb-Threatening Ischemia

Ask the Doctors Header Image, featuring Patrick Geraghty, MD shown to the right, with Critical Limb-Threatening Ischemia typed to the left.
Ask the Doctors: Critical Limb-Threatening Ischemia with Patrick Geraghty, MD

Limb ischemia is a peripheral arterial disease that causes reduced blood supply to the limbs. Long-term limb ischemia can progress into chronic limb-threatening ischemia (CL-TI), which requires immediate medical attention and treatment. Washington University vascular surgeon Patrick Geraghty, MD, is an expert in endovascular and surgical treatment of CL-TI. Chronic limb-threatening ischemia is sometimes called chronic limb-threatening ischemia for its risk of limb loss. Dr. Geraghty, who is a co-director of the Washington University Limb Preservation Program, answers questions about this condition and its progression, causes and risk factors, and treatment options.

Limb Ischemia

What is limb ischemia?

Limb ischemia is a peripheral artery disease (PAD) in which an obstruction of arteries reduces blood flow to the extremities, such as the hands, feet, and legs. The obstruction usually results from a buildup of plaque, known as atherosclerosis, causing an artery’s lining to progressively thicken. Atherosclerosis narrows or blocks blood flow, reducing circulation of blood to the legs, feet, or hands. Limb ischemia commonly affects the lower limbs, but the upper limbs and gluteals can also develop ischemia. The affected limb(s) may be pale or cold with a weak pulse. Other signs of limb ischemia include hair loss, changes in the appearance of skin, and thickened nails. In advanced cases, it can lead to lowered quality of life and severe conditions like sepsis or amputation.

What is acute limb ischemia?

Acute limb ischemia is defined as a limb ischemia that develops quickly or suddenly, leading to a decrease in blood perfusion. It produces new or rapidly worsening symptoms, often threatening limb viability. Acute limb ischemia is related to arterial occlusion or more rarely venous occlusion. Patients whose acute event has persisted over two weeks are considered to have chronic extremity ischemia.

What is chronic limb ischemia? What are the stages of limb ischemia as it progresses?

Chronic limb ischemia is an obstruction and loss of limb perfusion that has persisted over a period longer than two weeks. It presents similar or more advanced symptoms as acute limb ischemia.

Stages of chronic limb ischemia:

  • Stage I – Asymptomatic
  • Stage II – Intermittent claudication, which is pain affecting the calf, thigh or buttock, induced by exercise and relieved by rest
  • Stage III – Ischemic rest pain, or the presence of pain when no activity has induced it, often relieved by movement
  • Stage IV – Ulceration and/or gangrene, which will change the appearance and texture of skin

Chronic Limb-Threatening Ischemia (CL-TI)

What is chronic limb-threatening ischemia? 

Chronic limb-threatening ischemia (CL-TI) is the advanced stage of chronic limb ischemia. CL-TI is a serious condition that requires immediate treatment to re-establish blood flow to the affected limb. CL-TI has progressed to the point of severe pain and even skin ulcers or sores. The pain, also called “rest pain,” is often in the leg and can be relieved temporarily by hanging the leg over the bed or getting up to walk around. Clinical diagnosis of CL-TI is the presence of rest pain for over two weeks, visible severe skin changes, and low blood pressure in limb arteries.

What are warning signs of chronic limb-threatening ischemia? 

CL-TI has the same symptoms of chronic limb ischemia, along with any of the following symptoms:

  • Pain, numbness or a decrease in the temperature in the affected limb
  • Skin sores, infections or ulcers that won’t heal
  • Absent or diminished pulse in the limb
  • Shiny, smooth or dry skin
  • Thickening of the nails
  • Gangrene

What are the causes of chronic limb-threatening ischemia?

  • Native arterial thrombosis, such as atherosclerotic plaque, aneurysm, artery dissection or hypercoaguability
  • Post-procedural thrombosis
  • Embolisms and peripheral vasoconstriction or vasospasm
  • Traumatic injuries

What are risk factors for chronic limb-threatening ischemia?

The risk factors for CL-TI include:

  • Age over fifty
  • Smoking
  • Diabetes mellitus
  • High cholesterol
  • High blood pressure (hypertension)
  • Hyperlipidemia
  • Family history of vascular disease
  • Obesity and sedentary lifestyle

Chronic Limb-Threatening Ischemia Treatment

How do you treat chronic limb -threatening ischemia?

Treatment for CL-TI is based on the individual symptoms, but the goal is always to reduce the pain and improve blood flow to ultimately save the limb. The number one priority is to preserve the limb.

Treatments for CL-TI include:

  • Lifestyle changes: Changing behaviors related to risk factors can improve the incidence and severity of CL-TI. Reducing smoking, raising physical activity, and reducing body weight have been shown to reduce CL-TI symptoms.
  • Medications: Medicine may be prescribed to prevent the progression of CL-TI and to reduce contributing factors such as high blood pressure, high cholesterol or diabetes. Medication can also reduce the pain, prevent clotting or fight infections may also be prescribed.
  • Endovascular Treatments: These treatments are minimally invasive. A physician inserts a catheter into the blocked artery to allow access to the diseased portion of the artery. An angioplasty procedure can open blockages by placing and expanding small balloons introduced with a catheter. A metallic device called a “stent” is then inserted to preserve the expanded artery, maintaining blood flow. Other treatments include laser atherectomy, where lasers destroy small bits of plaque to open blocked arteries. Directional atherectomy is another procedure in which a catheter with a rotating cutting blade is used to physically remove plaque.
  • Arterial Surgery: If arterial blockages cannot be treated with endovascular therapy and aren’t resolved from lifestyle and medication changes, surgery may be recommended. This involves removing or bypassing the affected with a biological or synthetic graft. In other cases, the surgeon may dissect the artery and remove the plaque, maintaining the artery.

When does chronic limb-threatening ischemia warrant amputation?

Because treatment depends on the severity of the disease and individual symptoms, it is essential that a patient with ulcers or pain see a physician as soon as possible. The earlier a diagnosis is made, the earlier treatment can be started to prevent serious complications.

If other treatments have or will not improve the condition, the last recourse is amputation of an affected limb. Amputations are considered for patients who are unsuitable for revascularization procedures or those with ischemia causing incurable symptoms such as gangrene. Amputation occurs in about 25 percent of all CL-TI patients.

The Washington University Limb Preservation Program aims to save limbs whenever possible. We offer expedited second opinions for patients who have been recommended for major amputation. If amputation is necessary, our multidisciplinary team works with patients to return them to the highest possible quality of life.

Chronic Limb-Threatening Ischemia Treatment at Washington University

The Limb Preservation team at Washington University is dedicated to helping patients with a range of symptoms and severities of limb ischemia. Their patient-focused treatment program provides innovative, expert care to people at risk for amputation due to chronic conditions, including CL-TI. The multidisciplinary team of Limb Preservation surgeons is committed to preserving the form and function of limbs using the latest advances in surgery.

The department offers convenient, multidisciplinary care and physician teams to provide the best short-term and long-term health outcomes. The program offers timely testing and evaluation, wound healing and infection treatment. Teams work together to provide efficient care and surveillance, reduce the risk of a repeat problem and educate our patients.

To get in touch with our limb preservation team, please call 314-273-5462 (LIMB). For any emergent or time-sensitive limb preservation needs, please visit the Limb Preservation Team at the Charles F. Knight Emergency and Trauma Center at Barnes-Jewish Hospital.