Evaluation

Clinical Evaluation of Critical Limb Ischemia

History

The history of critical arterial insufficiency is dominated by pain; in most cases, the pain is severe, often intol-
erable, and it only responds to strong analgesics or opiates. The pain is caused by ischemia, areas of tissue loss,
ischemic neuropathy, or a combination of these; it occurs or worsens with reduction of perfusion pressure. In most
cases, walking capacity is very severely impaired, often becoming almost impossible. In rare cases, there also
may be foot claudication.
Ischemic rest pain most typically occurs at night but can occur even during the day when the patient is rest-
ing in supine position. The pain is localized in the distal part of the foot or in the vicinity of an ischemic ulcer
or gangrenous toe. The pain is often severe, enough to wake the patient at night and force him or her to rub
the foot, get up, or take a short walk around the room. Partial relief may be obtained by the dependent posi-
tion and application of heat, whereas elevation and cold increase the severity of the pain. Often, patients sleep
with their ischemic leg hanging over the edge of the bed, or sitting in an armchair all night; as a consequence,
ankle and foot edema develop, which further increases ischemia and pain. In severe cases, sleep becomes
impossible because pain sets in after only a few minutes of supine rest, causing in many patients a progres-
sive further decline of their general physical and psychological condition.
Often, pain is only relieved by large doses of strong analgesics or opiates. Not infrequently, this severe pain
precedes the formation of an ischemic ulcer or gangrene. Contracture of the knee and ankle joints may occur.
In more pronounced cases, foot claudication on an ischemic basis can occur; foot claudication is much less fre-
quent than calf intermittent claudication and occurs mainly in thromboangiitis obliterans rather than in arte-
riosclerosis obliterans. It is characterized by a painful ache or cramp in the forefoot associated with walking.
These patients often also complain of a “wooden” sensation of numbness in the limb or foot (see “Differential
Diagnosis”, p. 60). At the time of ulcer formation, patients occasionally experience a short, temporary relief of
pain; however, some time later, pain most often increases again because of local infection or inflammation. In
cases in which there is gangrene formation, the pain further increases, only diminishing or totally disappearing
when complete gangrene of the ischemic part has developed. Again, the degree of involvement of the periph-
eral sensory nerves plays an important role in this process.
Ischemic rest pain is often accompanied by pain caused by peripheral ischemic neuropathy, the mechanism
of which is not well established. This results in severe, sharp, shooting pain that does not necessarily follow the
anatomic distribution of the nerves but usually is most pronounced at the distal part of the extremity. The pain
often occurs at night, with paroxysms lasting minutes to hours but with constant diffuse pain remaining in between.
Temperature sensation can be very disturbed in such patients. This may cause very cold sensations during parox-
ysms, which suddenly become intolerably hot afterwards; because of such neuropathy, patients cannot tolerate
any physical compression of the leg. Even the weight of bedclothes causes too much pain; removing the bed-
clothes in turn decreases the temperature of the ischemic limb and increases pain.

191

or wherever local pressure has caused further decrease of perfusion. Capillary blush is severely delayed after pressure on the pulp of the digit. below). if not infected. it may involve the distal parts of the forefoot. To objectively confirm the diagnosis. In more advanced cases. not uncommonly a companion ulcer develops on the adjacent toe (“kissing ulcer”). in acute conditions. which in many cases leads to a decrease in pain. use of local heat) also can cause ulcer and gangrene formation on any other place of the foot or leg. In patients with Buerger’s disease or with venous insufficiency. indicating the change in perfusion. gives rise to local reactions such as the production of exudate and pus. 192 . In such cases. Spontaneous amputation sometimes follows. Investigations for Critical Limb Ischemia Introduction Although the history and physical examination. there is significant proximal stenosis or occlu- sion causing diminished arterial pulses and bruits at the femoral or iliac arteries. Such ulcers are often infected and give rise to ascending cel- lulitis and lymphangitis. They also occur at the inner surface of the digits. localized infarctive lesions. Arterial ulcers usually involve the tips of the toes. Localized pallor or cyanosis associated with poor capillary filling is usually a prelude to ischemic gangrene or ulceration. the least local pressure or elevation of the leg is sufficient to induce a cadaveric pallor. 2. there is atrophy of the skin and its appendages. The subcuta- neous tissue atrophies so that the foot becomes shiny. and in such cases the clinician should observe the direction of blood filling the distal veins from proximal to distal. further diagnostic studies are usually needed. the heel of the foot. Sometimes. as just described. Also. but unless this is unilateral and produces asymmetry. The dependent toes may appear so red and may refill so rapidly after pressure application that the uninitiated may mistakenly consider this to be evi- dence of hyperemia rather than an expression of severe ischemia (Buerger’s/Ratschow’s sign). These may lead to crust formation. as occurs in many cases. Any minor local trauma such as cutting the toenails may elicit formation of an ulcer and lead to gangrene. the base of the ulcer is pale unless inflam- mation or infection. there may be rubor on dependency because of chronic dilatation of the precapillary and postcapillary vessels. These investigations have a num- ber of purposes: 1. local pressure (shoes. scaly. the skin may feel warm around spots with inflammation or infection. often makes the diagnosis of CLI with cer- tainty. Arterial ulcers due to obliteration of the main inflow arteries should be differentiated from ulcers caused by venous disease. Loss of hair growth over the dorsum of the toes and foot is another relatively common sign of severe arterial insufficiency. skin palpation may show a line below which temperature drops suddenly. the color of the skin is usually extremely pale or cyanotic. long-standing cases. Absent stretch reflexes and loss of vibratory sense are early signs of neuropathy. venous filling after dropping the elevated limb back into the dependent posi- tion is very slow. In most patients. Specificity and sensitivity of these tests is not well known but presumably is rather low. and “skeletonized. has a tendency to shrink and eventually lead to mummification of the part affected. it may escape detection. In severe. Arterial ulcers typically have irregular borders. false normal figures for venous filling can be obtained because of inverse flow in the veins. for clinical decision making. exam- ination of the other vascular areas and of the cardiac status should complete the physical examination in all patients.” This may be obscured by ankle and foot edema caused by leg dependency at night. in severe cases. Objective tests should always be included (see “Investigations for Critical Limb Ischemia. 200). it often is accompanied by thickening of the toenails secondary to slowness of nail growth.Physical Examination of Critical Limb Ischemia Severe ischemia is often associated with atrophy of the calf muscles. Gangrene usually affects the digits. Gan- grenous tissue. and neurotrophic ulcers (see p. To localize the responsible arterial lesions and grade their relative severity. Detection of distal arterial pulses does not preclude severe ischemia in cases of very distal occlusions such as in peripheral microemboli or some diabetic patients. Skin temperature is low. covering the ulcer surface.

Basic Hematologic and Biochemical Tests The following laboratory tests should be performed (see also “Investigations of Patients with Intermittent Clau- dication”. 68): — complete blood count (hemoglobin. other indirect studies may be of adjunctive value. Such stud- ies also contribute to the evaluation of operative risk. — erythrocyte sedimentation rate in selected cases (see p. The latter two have already been addressed in p. “Intermittent Claudication. Here ankle or toe pressures can be helpful. It is a good practice to measure toe pressure in all patients with suspected critical limb ischemia. 65 (“Routine Tests”) and are not repeated here. hematocrit. 65. are needed. The imag- ing techniques discussed in p. As with the patient presenting for the first time with claudi- cation. To address the first three points. — platelet count. so that their applications in this setting are discussed in some detail. confusion may occur. The following discussion will therefore build on the basic information already pre- sented in section B. and patients with no signs of ath- erosclerosis. — blood glucose or hemoglobin A1c. Treadmill testing. which are the same levels used to confirm a SVS/ISCVS grade II or category 4 level of ischemia. female patients. many of the same investigations as discussed for patients with intermittent claudication are employed but in quite a different way. and Recommendation 13. To assess operative risk and operative strategy. because intervention is very likely to be undertaken. Ankle and Toe Pressure Measurements Ankle pressure should be measured in all patients. When they present with foot lesions. p. As characteristic as ischemic pain is. 6. in a nondiabetic patient with an ankle pressure above 50 mmHg or a diabetic with a toe pres- 193 .” by emphasizing the specific applications that have proved useful in evaluating chronic critical limb ischemia (CLI). Additional Tests for Atypical Patients In special categories of patients such as younger patients. To assess the need for intervention (by predicting the outcome of conservative management) and help in the choice of procedure. Should an operative intervention be necessary. Certain basic investigations. are more likely to be indicated in CLI patients than in the claudicant. — urea. 66). — lipid profile. 5. It should be noted that common practice in relation to noninva- sive investigations may differ widely between Europe and North America. homocysteine levels and the hypercoaguability screen can be evaluated (see Recommendation 14. In addition to obtaining ankle or toe pressures. 3. In such cases. is not applicable. False high values can be obtained in diabetic patients. Thus. and it is even more likely therefore that arte- riography will be performed. Transcutaneous oxygen measurements (TCPO2) and radionuclide perfusion scans are described with their applications. to estimate distal perfusion. particularly in patients with diabetes who suffer neuritic pain at early stages of their neuropathy. additional diagnostic studies may be needed. Seg- mental limb pressures (SLPs) combined with either segmental plethysmography (PVRs) or Doppler velocity wave form (VWF) may have application in CLI patients. mainly uncovering atherosclerotic risk factors. however. white cell count). Ischemic rest pain most commonly occurs below an ankle pressure of 40 mmHg and a toe pressure of 30 mmHg. 69). 23 (“Imaging Techniques”). the presumption is often made that they have CLI. p. creatinine. toe pressure should be measured. Some dia- betic patients suffering neuropathy do not develop pain to such an extent that this symptom will be a presenting feature. The involvement of other systems with arteriosclerosis needs to be explored. 4. p.

a clearly pulsatile toe or transmetatarsal PVR would make rest pain unlikely. In general. The flux data obtained do not come from the capillaries alone and do not allow distinction between nutritive and nonnutritive flow.1 A wide range of values is therefore seen in “normal” subjects. metabolic activity. Microcirculatory Investigations Transcutaneous oxygen measurements (TCPO2) Modified Clark polarographic electrodes are used to measure oxygen tension in the cutaneous capillary bed. its value in estimating nutri- tive perfusion is limited because it is an indirect measure of skin perfusion and is not necessarily derived from cap- illaries only. an oxygen tension of 30 mmHg suggests ischemia and nonhealing. if capillaries can be visualized. others initially have other causes (eg.75:1 predicts healing with almost 90% accuracy.11- 13 At rest in critical limb ischemia.sure above 40 mmHg. peak red blood cell velocity during reactive hyperemia and the resting TCPO2 at 44°C appear to provide a valuable set of parameters in detecting critical limb ischemia.7 For instance. TCPO2 is already low in patients with relatively mild ischemia. Some ulcers are ischemic from the outset. whereas a flat line tracing would suggest the pain is ischemic. whereas lesions with a ratio less than 1. oxyhemoglobin dis- sociation. In older patients. their morphology can help in estimating underlying diseases such as systemic collagen disease. when reactive hyperemia is applied. and oxygen perfusion through the tissues.14 194 . and this may prove useful in the future. extremely low flow values are obtained. traumatic. LDF and radionu- clides can be monitored using pressure cuffs to determine local skin perfusion pressure. Laser Doppler fluxmetry Laser Doppler fluxmetry (LDF) estimates local skin flow. or neu- rotrophic) but will not heal because of the severity of underlying PAD. illus- trating poor oxygen diffusion through the skin.5:1 rarely heal with time. skin blood flow can often be surprisingly high because of permanent dilation of the ischemic cutaneous arterioles. The values obtained represent a complex function of cutaneous blood flow. taken in the supraclavicular or infraclavicular region adds perspective (much as when comparing the brachial pressure with the ankle pressure). TCPO2 is helpful to estimate the degree of ischemia. with 201Thallium. other causes of rest pain should be considered. venous. it might be pre- dicted that healing will not occur with a TCPO2 under 20 mmHg and will occur with a TCPO2 over 40 mmHg.2-5 Thus. Also. Healing requires an inflammatory response and additional perfusion above that required for supporting intact skin and underlying tissues. however. but the interpretation of the results is often difficult because the investigation requires the temperature of skin to be increased first. Radionuclide perfusion scans Perfusion scans of the foot using a variety of radionuclide labels may be helpful in this setting. The ankle and toe pressure levels needed for healing are therefore higher than the pressures found in ischemic rest pain. because they show whether a sufficient inflammatory response is present to support healing. In contrast to capillary microscopy. which quickly enters the cells on passage through the circulation after intravenous injection.6 However.9 10 Capillary microscopy Capillary microscopy is useful to estimate tissue ischemia. or those with car- diopulmonary disease.8 However. Using a gamma camera and com- paring the counts in the hyperemic zone around a foot lesion with those in a representative background elsewhere in the foot gives a simple ratio that can predict healing. a ratio of 1. but a range of ±10 mmHg must be allowed. Capillary microscopy and TCPO2 give additive information as to the severity of the ischemia. a comparative value. it has a high positive predictive value (77%–87%) for classifying patients as having severe ischemia.

Using a Combination of Tests Because no test alone is completely reliable. TCPO2 measurements. Nevertheless. the necessary digit for performing toe pressure mea- surements is often necrotic. Unless noninterventional measures are to be tried. p. Tests can be expensive. 72 and Recommendation 18. A pulsatile transmetatarsal PVR or a TCPO2 over 40 mmHg or a 201Thallium perfu- sion scan ratio of 1. it is of practical importance that the vascular specialists involved in this decision be present and confer at the completion of arteriography. it increases the speed of treatment initiation. or a radionuclide scan. if the ankle pressure is greater than 70 mmHg and the toe pressure is greater than 40 mmHg. For example. but a higher toe pressure (50 mmHg) is used to indicate certain healing. Radionuclide measurements of skin perfusion (Xenon or other radionuclides used with or without pressure cuffs) are more accurate but are also expensive and not widely available or used. and in patients with diabetes. several tests may be required to evaluate a patient with CLI.21 195 . the discussion of imaging in “Imaging Techniques” (see p. the evaluation of patients with CLI and prediction of healing is assessed on clinical grounds by the responsible surgeon.20 Although the technique is best for lesions above the popliteal arteries. in most cases. These tests are of more practical value in deciding whether toe or transmetatarsal amputations will heal without the aid of a revascularization procedure. and the seg- mental location and relative severity of the responsible occlusive lesions is known. performing the least number of tests. The techniques that have been tried to assess healing of amputations at different levels are discussed in detail in “Combined Surgical and Endovascular Procedures” (see p. and this. and beginning with the least expensive and least time consuming. sav- ing the patient a second procedure and additional time in the hospital. Ankle pressures are not predictive of healing unless over 70 mm Hg in a nondiabetic. spon- taneous healing will probably occur. along with clearly high values. p. starting with measurement of Doppler arterial pressures. In only a minority of cases is it necessary to proceed to tests such as PVR. Duplex scanning is often used as a first technique to characterize the lesions. This is an important deci- sion because it can govern the decision to intervene. so a sequential approach may be used. If a percu- taneous intervention is deemed to be the most appropriate initial intervention. if SLPs and PVRs have been obtained. but no single value at one particular level is reliably predictive of healing. it may proceed at that point. 74). because of the quick and noninvasive approach. the same approach could be used. these tests indicate the levels and severity of the underlying occlu- sive disease.15-21 However. detailed anatomy of the lower extremity arterial tree is required. rteriography in selected patients with CLI. A plain radiograph of the foot may be useful to exclude osteomyelitis. and this almost always requires arteriography (see Recommendation 17.75:1 taken at the edge of the line of demarcation are all reasonably predictive of healing. In gen- eral. Duplex scanning and MRA are being increasingly tried as a substitute for. Some consult the results of SLP and PVR. Because this final information may determine the procedure of choice. In general. a complete angiogram from the level of the renal arteries to the level of the pedal arch should be performed to correctly plan treatment. can be quite helpful. 73) applies equally well to CLI patients. 232). reliable results have been shown to detect crural and pedal artery lesions as well. Imaging Because patients with CLI commonly have multilevel involvement of arteries. In a patient with diabetes. only the morphological anatomy is not. or to limit the extent of.

visceral.Assessment of the Risk of Interventional Options Patients with CLI usually not only have multilevel disease in the involved extremity but also have a higher like- lihood of significant atherosclerosis in other circulations. First. but universally agreed-on selection criteria have not been developed. occult MI by ECG. a Duplex scan of the carotid arteries should be considered in patients at higher risk of carotid disease22 or if a bruit is heard. It largely centers around investigating concurrent disease. cardiac perfusion scans. echocardiography. a trans- esophageal echocardiogram is most often required. however. the test(s) generally should not be obtained unless one is willing to pursue a finding of significant coro- nary disease with some intervention such as PTCA or coronary artery bypass graft (CABG). however. Conversely. ambulatory Holter monitoring. diversion to pursue otherwise elective coronary revascularization will likely result in amputation. to detect the cardiac origin of emboli. Similarly. episodes of congestive failure) or factors associated with high risk (eg. Noninterventional treatment is more likely to suc- ceed in those with recent onset or easily controlled ischemic rest pain or those with shallow ulcers. even if the degree and durability of benefit with the latter procedures is inferior. a contemplated infrainguinal bypass in a claudicant might be abandoned if significant coronary disease were uncovered. the risk from coronary disease increases with the need for open intervention. so that the main application of these tests are in screening patients before surgical revascularization. This might be appro- priate in some patients with intermittent claudication. Clinical scoring systems to assess the risk of adverse cardiac events associated with operation have generally not succeeded to predict this risk with sufficient accuracy in patients with PAD. are a higher operative risk. an ankle pressure above 40 mm Hg and a toe pressure or TCPO2 above 30 mm Hg would increase the likelihood of success of such measures. dipyridamole thallium scan). and particularly while undergoing surgical interventions. as has the frequency of adverse cardiac events over time. data to sup- port multifactorial risk index–based preoperative screening that can identify low-risk patients.24 Those with evidence of multisystem atherosclerosis (eg. some general guidelines can be suggested. However. Second. The main value for additional screening for these patients relates to the likely need for intervention and particularly the cardiac risks of any major operation. or radionuclide ventriculography have all been found not to be cost-effec- tive when applied routinely. and have a more limited life expectancy compared with patients with intermittent claudication. and one of considerable recent interest and controversy. such screening tests should not be obtained unless the result is likely to modify the management of the PAD. The high prevalence of coronary disease in patients with PAD has already been discussed in earlier sections. An important question. it is also clear that success is more likely in those whose perfusion is reduced to just below the accepted categorical levels mentioned above. particularly in vital organs and coagulation systems.23 Additional screening in claudi- cators might be valuable because claudication may mask angina (and thus otherwise clinically significant coro- nary disease) by restricting exercise. Thus. or even coronary angiography. An echocardiogram should be done when embolization is suspected from heart valves or dilated left heart cavities. Even in these cases. such as cardiac treadmill test- ing. an axillobifemoral bypass or PTA with multiple stents might be chosen over an aortobifemoral bypass. 65). age older than 70 years). carotid. Third. For example. Special attention should be given to the coronary and cerebral circulation: a rest- ing ECG should be recorded in all patients. those with CLI are often too frail or unable to walk on the tread- mill because of foot lesions.27 196 . Nevertheless. the risk is low unless clinical indicators of coronary disease are present. but in a patient imminently facing limb loss without successful leg bypass. is how much further beyond a cardiac history and a resting ECG one should go in such patients with special tests. Finally. Much of it overlaps with the routine tests for the assessment of atherosclerosis in other systems. already discussed in “Inter- mittent Claudication” (see p. dobutamide stress echocardio- graphy. However.24 There are. if significant coronary disease were found in a patient with ischemic ulcers on both feet. his- tory of MI.2-5 The assessment of operative risk is to a large extent generic and beyond the scope of this document. such measures would be fruitless in those with pressures of 20 mm Hg or less. diabetes.25 26 Adding special screening tests such as cardiac perfusion scans (eg. cardiac screening tests are best applied to those with clinical or ECG evidence of coronary disease (angina. or leg arter- ies) might be included here.

it uses a number of intraoperative parameters so that it cannot be applied prospectively. — imaging of the lower limb arteries in patients considered for intervention. Diabetes Care 1997. — assessment of atherosclerosis in other systems. — assessment of the hemodynamic requirements for successful intervention (vis a vis proxi- mal vs combined revascularization of multilevel disease). — assessment of individual patient operative risk. specific for types of vascular inter- ventions and applicable to individual patients on the basis of their risk factors. Abbott WM. Determination of amputation level in ischemic limbs: reappraisal of the measurement of TcPO2. Even though it may be the best risk analysis system available. 4. A comparative analysis of transcutaneous oximetry (tcPO2) during oxygen inhalation and leg depen- dency in severe peripheral arterial occlusive disease.28-31 Each incorporates different diagnostic and procedural parameters. J Vasc Surg 1992.49(3):315-324. Megerman J. Predictive value of transcutaneous oxygen pressure and amputa- tion success by use of supine and elevation measurements. such as APACHE II and POSSUM. The latter applies to all surgi- cal operations but has been shown to correlate with mortality in a vascular surgical unit. 2. Rooke TW. 197 . 147:510-517. Bacharach JM. Am J Surg 1984. Katsamouris A. and it is not specific for vascular procedures. — resting ECG. Rieger H. Ubbink DT.20:1315-1318. to allow preoperative risk assessment of different vascular procedures for individual patients.16:218-224. the following investigations should be used in patients with critical limb ischemia: — complete clinical history and examination. RECOMMENDATION 78: Objectives for diagnostic evaluation of patients with critical limb ischemia The diagnostic evaluation of patients with critical limb ischemia should be directed toward the fol- lowing objectives: — objective confirmation of the diagnosis. — basic hematologic and biochemical tests (see Recommendation 13. Jacobs MJ. 3. Cina C. Transcutaneous oxygen tension in selection of amputation level. — a more detailed coronary assessment in selected patients. Osmundson PJ. — localization of the responsible lesion(s) and a gauge of relative severity. References 1. Brewster DC. it is generic. Can transcutaneous oximetry detect nutritive perfusion disturbances in patients with lower limb ischemia? Microvasc Res 1995 May. p. Wutschert R. Slaaf DW. 5. — assessment of atherosclerotic risk factors. Attempts have been made to assess individual patient risk in a systematic manner. RECOMMENDATION 79: Investigations for evaluating patients with critical limb ischemia To achieve the objectives listed in Recommendation 78. CRITICAL ISSUE 28: Preoperative risk assessment in patients with critical limb ischemia There is a need for a system for preoperative risk assessment. Gloviczki P. J Vasc Surg 1992. Scheffler A. Darling RC. This approach is being explored by the ad hoc committee on reporting standards of the SVS/ISCVS. What is needed.15:558-563. including the coronary and cerebral circulation. is a system that uses preoperative para- meters and is specific for vascular surgery and uses a severity grading scale for each type of vascular operation. — duplex scan of the carotid arteries should be done in selected patients at high risk. — ankle or toe pressure measurement or other objective measures for the severity of ischemia. 68). Bounameaux H.

Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Darling RC. Value of duplex scanning in evaluation of crural and foot arter- ies in limbs with severe lower limb ischaemia: a prospective comparison with angiography.326:1577-1581. Fagrell B.274:875-880. Gertler JP.80:354-358. Philadelphia. 1994 Jan-Apr. Geller S. Angiology.14(1-2):34-44. Comparative vascular audit using the POSSUM scoring system. Brundage BH. Slaaf DW. Birkenhager WH. PA: Saunders. 18.13:818-829. 12. Freeny PC. Cambria R. Kitslaar PJ. 24. Crit Care Med 1985. Johansson SR. Ewy GA. Rutter CM.7:684-689. Eur J Vasc Endovasc Surg 1996 Oct.85:209-212. Fleisher LA. Magnetic resonance imaging of angiographically occult runoff ves- sels in peripheral arterial occlusive disease. 29. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Level of arterial obstruction in patients with peripheral arterial occlusive disease (PAOD) determined by laser Doppler fluxmetry. 11. Mahmood T. Nehler MR. Circulation 1996. Fagrell B. Comparison of POSSUM with APACHE II for prediction of outcome from surgical high dependency unit. 21. Butterworth P. Ohta T. In: Hansson L.4:403-411. Knaus WA. Sunshine JH. de Buyzere D. Varty K. Comparison of POSSUM and the Portsmouth pre- dictor equation for predicting death following vascular surgery. Janssen HA. Pentecost MJ. Wijesinghe LD. Copeland GP. Reneman RS. Capillary microscopy is a diagnostic aid in patients with acral ischemia.72:892- 895. Critical evaluation of venous occlusion plethysmography in the diagnosis of occlu- sive arterial diseases in the lower limbs. Nydahl S. Jones DR. Karacagil S. 14. J Vasc Surg 1997. Ann Intern Med 1997. 6. Yin D. Nghiem HV.75:175-177. Int J Microcirc Clin Exp. Vascular Surgery. Draper EA.126:337-346. Yuan C. Swedenborg J. Duprez D.4:69-74. Jacobs MJ. 5th ed. Schreurs MM. 19. et al. Kaufman JA.25:380-389. Skin microcirculation in diabetic and non-diabetic patients at different stages of lower limb ischaemia. Wagner DP. The incidence of periperative myocardial infarction in general vascular surgery. Moneta GL.110:859-866. 16. MR angiography of the peripheral vasculature. 31. Lee TT. Changes in the management of critical limb ischaemia. de Cossart L. 25. Schmiedl UP. Ann Intern Med 1989. 15. Reneman RS. Zimmerman JE. Ubbink DT. Cost-effectiveness of MR angiography in cases of limb-threat- ening peripheral vascular disease. 30. Combining clinical and thallium data optimizes preoperative assesment of cardiac risk before major vascular surgery. Owen RS.7:659-666. Strauss HW. Jones D. Magnetic resonance angiog- raphy in the management of lower extremity arterial occlusive disease: a prospective study. Baum RA. ed. Clement D. APACHE II: A severity of disease classification system. Brewster DC. 28. Hertzer NR et al. Van Maele GO. McConnell DB. Clin Physiol 1984. Eur J Vasc Surg 1993. Scheffler A. Ubbink DT. 9. In: Rutherford RB. Noninvasive technique using thallium-201 for predicting ischemic ulcer healing of the foot. Granbo A. 10. Eagle KA. Multicenter trial to evaluate vascular magnetic resonance angiography of the lower extremity. 13. Oehlert J. Coley CM. Garger AM. Ann R Coll Surg Eng 1993. Newell JB.46(1):59-64. London NJ. Carpenter MDJ. Cope C. Kent PJ. De Pue N. Blebea JS. Wilcox A. Semin Ultrasound CT MR 1996. Clement DL. Chaitman BR. Carpenter JP. N Engl J Med 1992. Olofsson P. Jacobs MJ. Lindberg G. Errington M. Hallenberg B. Perloff LJ. Frid I. Harris PL. 26. Int J Microcirc Clin Exp 1992. Porter JM. Assessment of Hypertensive Organ Damage. Blebea J.15:52-59. 1997:85-104. 83(7):953-956. Brewster D. Int Angiol 1985. 17. 198 . Carpenter JP. Cardiac risk and peripheral vascular surgery: new approach based on a multifactorial risk index.11:249-261. 1996 Jul. Kester RC. Radiology 1995. Guidelines for perioperative cardiovascular evaluation for non cardiac surgery. Tordoir JH. JAMA 1995. Lofberg AM. A simplified evaluation of vital capillary microscopy for predicting skin viability in patients with severe arterial insufficiency. transcutaneous oximetry and laser Doppler fluxmetry in the assessment of the severity of lower limb ischaemia. 22.12(3):300-303. Elsevier Science BV. Cost-effectiveness of screening for carotid stenosis in asymp- tomatic persons. Ubbink DT. Heidenreich PA. Winter TC. Copeland GP. Jivegard L. 1995 Jan. LíItalien GJ. Yeager RA. Jacobs MJ. eds. Eur J Vasc Surg 1993. Holm J. Cardiac complications and screening. Rieger H. American College of Radiology Rapid Technology Assessment Group. Baum RA. 20. Langlotz CP. Spontaneous oscillations of laser Doppler skin blood flux in periperal arterial occlusive disease. Br J Surg 1985. J Vasc Surg 1992. Haljamae H. Br J Surg 1992. Bergqvist D. 7. Tangelder GJ. Handbook of Hypertension. Br J Surg. Amsterdam. Berridge DC.17:404-411. 23. Scott DJ. La Muraglia GM. 8. 2000. Taylor LJ. Wahlberg E. Br J Surg 1993. Baum RA. The usefulness of capillary microscopy.194:757-764. 27. Eagle KA. et al. vol 18. Lorelius LE. Br J Surg 1998. Bolia A. Solomon NA.79:1293-1296. Bell PR. et al.93:1278- 1317. Krupski WC.

sensory neuropathy can result in severe. however. Rarely it follows shin- gles2 or some other peripheral neuritis. pale with trophic changes. Differential Diagnosis of Critical Limb Ischemia Differential Diagnosis of Ischemic Rest Pain The various causes of foot pain that may be mistaken for ischemic rest pain are considered in their approxi- mate order of frequency. as it is commonly called. and S1 over the extensor surface of the foot with diminished ankle reflex. Theories are numerous. L5 compression can produce pain on the medial edge of the foot.4 A mild degree of nonpitting edema is commonly seen as shiny skin and is not relieved by elevation. It is typi- cally associated with backache and the pain distribution following one of the dermatomes. and autonomic imbalance with vasomotor phenomena. causalgia. are often mistakenly referred to vascular surgeons or other vascular specialists. The patient may have other signs of a diabetic neuropathy. Diagnostic features that may be helpful are a symmetrical distribution in both legs. such as decreased reflexes. vascular surgeons have perfected and made safe this procedure. close to complete pain relief).3 The diagnostic triad consists of pain (often burning). in a minority of diabetic patients. Physical examination also may show limited straight leg raising. L4 compression there- fore includes pain in the big toe and diminished knee reflex. 280). hypersensitivity (usually along the course of a dermatome or peripheral nerve). Osteoporosis is usu- ally seen in established cases. but this may be preceded by a positive bone scan. Before this late stage. The disuse associated with pain avoidance may ultimately lead to ankylosis. giving rise to continuous pain. with one large series describing 829 patients presenting in one specialized center over 8 years. Although some form of trauma to peripheral nerves is the accepted initiating cause of causalgia. Reflex sympathetic dystrophy Patients with reflex sympathetic dystrophy. and in late stages. the trauma may be so trivial that it is missed in the history. the patient not having made the association.1 Diabetic sensory neuropathy Although diabetic neuropathy usually results in loss of function and anesthesia. which can be confused with ischemic rest pain. One form of causalgic pain is caused by inadvertent ischemic dam- age to peripheral nerves after delayed revascularization and therefore may be encountered as a postoperative complication in patients with PAD. seriously disabling pain in the foot. but the cause is unknown. The latter usually consist of mottling cyanosis and hyper- hidrosis. p. which provides dramatic and lasting relief from causalgic pain.5 Nerve root compression A number of spinal conditions may result in nerve root compression. making it more difficult to distinguish from atypical ischemic rest pain. This may be fortuitous. because although sympa- thectomy is now rarely used for CLI or any other vascular disease (see “Sympathectomy in the Management of Critical Limb Ischemia”. Peripheral neuropathy other than that caused by diabetic neuropathy may be caused by 199 . Reflex sympathetic dystrophy is not an uncommon condition. the diagnosis may be confirmed by a truly dra- matic response to sympathetic block (ie. This is often described as a burning or shooting sensation that is frequently worse at night. but in early stages the limb may be warm and dry. but sympathetic block will produce some degree of amelioration in most extremity pain. or. Peripheral sensory neuropathy other than diabetic neuropathy Any condition giving rise to isolated sensory neuropathy can produce pain in the foot. association with cuta- neous hypersensitivity and failure to relieve it by dependency of the foot.

including local inflammatory dis- eases such as gout. and commonly used drugs may produce a rare peripheral neuropathy. very rarely the foot alone. Ulcer- ation is usually preceded by a long period of trophic changes in the skin. Leprosy also may rarely result in a neuropathic ulcer.vitamin B12 deficiency. tox- ins. tarsal tunnel nerve compression.—Etiological classification of foot and leg ulcers.6 Night cramps Simple night cramps. the vari- ous causes of ulcers are considered in approximate order of frequency in Europe and North America. syringomyelia. In the following text. but it is now recog- nized that they also can arise as a result of superficial venous incompetence without any deep vein disease. but their precise cause is unknown. Buerger’s disease Buerger’s disease also may present with rest pain in the toes or foot. They are usually associated with muscle spasm and usually involve the calf.7 Table XXXIX shows the differential diagnosis of common foot and leg ulcers. They may be associated with chronic venous insufficiency. the skin can become white. The usual history is a patient with a TABLE XXXVIII. although at a later stage. particularly after healed ulceration. Classically they were believed to follow 10 to 20 years after deep vein thrombosis. or plantar fasciitis. Diagnostic problems usually arise with mixed venous and arterial ulcers. digital neuroma. rheumatoid arthritis. Venous insufficiency Hematologic Larger arteries Sickle cell anemia PAD Polycythemia Emboli Leukemia Buerger’s disease Thalassemia Microcirculatory Thrombocytopenia Diabetic microangiopathy Malignancy Vasculitis Squamous cell carcinoma Collagen diseases Kaposiís sarcoma Neuropathic Secondary metastases Diabetes mellitus Lymphosarcoma mycosis fungoides Vitamin B12 deficiency Miscellaneous Leprosy Gout Pyoderma gangrenosum Necrobiosis lipoidica Drugs Mycotic Artifactual or factitious 200 . Alcohol intake. typically above the medial (internal) malle- olus. as opposed to restless legs. Initially there is usually hyperpigmentation. Miscellaneous A number of other miscellaneous conditions can give rise to pain in the foot. Venous ulcers Venous ulcers are the long-term consequences of a raised venous pressure secondary to chronic venous insuf- ficiency. Diagnosis is usually easy on the basis of the typical site of the ulcer just above the ankle and evidence of long-standing chronic venous insufficiency. Differential Diagnosis of Ulcers Table XXXVIII is an abbreviated etiological classification of foot and leg ulcers. are very common and occasionally difficult to diagnose.

all of the components of a neuropathy may play a part in ulceration. because the arterial circulation is nor- mal. in patients with diabetes. there is usually an increased blood flow. hypertension often multiple Neurotrophic Neuropathy Foot sole None Often deep.9 10 Diabetic neuropathic ulcers Most neuropathic ulcers occur in patients with diabetes. and 30% of these hospitalizations are for foot problems.11 The distinction is important. In neuropathic ulcers. The ulcers are often multiple. Several stud- ies have shown that approximately 10% to 15% of venous ulcers also have a significant arterial component. It is therefore essential to assess accurately the arterial circulation in any patient who appears to have a venous ulcer. pale base acute occlusion Venous Venous disease Malleolar Mild Irregular. small. infected sequence of venous ulcers. further immunologic testing should be performed. and it is often the presenting symptom of non–insulin- dependent diabetic patients.12 In patients with diabetes. such as renal failure. It causes a progressive narrowing of the distal arteries characterized histo- 201 . Buerger’s disease (thromboangitis obliterans) Buerger’s disease is very rare in Western Europe and North America. which have been poorly categorized. foot Severe Irregular. The pure neuropathic ulcer is easy to identify. The incidence in patients with diabetes of pure ischemic. Lower third of leg Severe Small after infarction. Sensory neu- ropathy removes the protective pain sensation after acute or chronic trauma. Vasculitis and collagen diseases This is a miscellaneous group of conditions.8 patients with long-standing venous ulcers tend to be in the age-group in which they are also likely to develop arterial disease. The diagnosis may be suggested by other systemic manifestations of the disease. pink base Skin infarct Systemic disease.—Differential diagnosis of common foot and leg ulcers. provided all pressure is removed from the ulcerated area. but it is almost as common as athero- sclerosis in other parts of the world. there is a whole spectrum of ulcers from the pure neuropathic to the pure ischemic ulcer. embolism. This may be caused by the development of significant arterial disease superimposed on earlier venous insufficiency. because it will have a bearing on the patient’s treatment and prognosis: in the United Kingdom. The commonest form is associated with systemic lupus erythematosis. Palpable pedal pulses do not rule out significant arterial obstruction more distally in diabetic patients. and pure neuropathic ulcers will heal without any form of intervention. However. Treatment will have to be modified. and exquisitely tender. Table XL is a guide to the differential diagnosis of the neurological and neuroischemic diabetic ulcer. pure neuropathic. which gradually become more difficult to heal by the usual methods of compression bandaging and elevation. Buergerís. The patient may have a low-grade intermittent fever.TABLE XXXIX. because compression bandaging is clearly inappropriate if the patient has a significant arterial component to the ulceration. and blood tests often show a raised ESR and C-reactive protein con- centration. and establishing the relative importance of these two mechanisms in patients falling between the two extremes is particularly difficult. and mixed neuroischemic ulcers are about equal. 4% of hospital beds are occupied by patients with diabetes. Although atherosclerosis is no more common in patients with venous ulcers than in the general population. If these conditions are suspected. Origin Cause Location Pain Appearance Main arteries PAD. Toes. Pure sympathetic neuropathy will result in a dry fissured skin that is more prone to infection. Abnormal pressure points may develop on the foot because of the motor neuropathy affecting the small muscles of the foot to a variable extent and pro- ducing the typical claw appearance seen in patients with diabetes.

The characteristic features of Buerg- erís disease are as follows: — often present with foot ulcers. Buerger’s disease usually presents with ulceration or necrosis at the tip of the toes or fingers. — Raynaud’s phenomenon. long-standing venous ulcers may undergo malignant change in which an elevated. The site is usually similar to venous ulcers. — involves the venous system as well as the arteries. Neuropathic ulcer Neuroischemic ulcer Painless Painful Normal pulses Absent pulses Typically punched-out appearance Irregular margins Often located on sole or edge of foot Commonly located on toes Presence of calluses Calluses absent or infrequent Loss of sensation. The cutaneous lesions in Kaposi’s sarcoma most often begin around the feet and ankles as reddish-brown nodules that can go on to ulceration. warm foot Cold foot Bone deformities No bony deformities Red appearance Pale. reflexes. claudication is rare.TABLE XL. nor a specific medical treatment. but the histological appearance of the small arteries and the accompany- ing veins in the affected parts is typical. — onset of symptoms usually before 40 and always before 50 years of age.15 Other causes of hematologic ulceration are acute or chronic leukemia. and specific blood tests should be performed to exclude the diagnosis. can occur in the foot. — Malignant ulcers. In addition. Usually improved by cessation of smok- ing. intermittent claudication is rare. and throm- bocythemia. The incidence of ulcers can be as high as 25% to 75% in patients with sickle cell disease. — apart from the distal distribution of the lesions. It is a diagnosis that should be thought of in all black patients. which rapidly turn into ulcers. — may affect the upper as well as the lower limbs. There are a number of theories about its etiology. mostly centered around smoking. cyanosed logically by an active acute inflammatory appearance.—Differential diagnosis of neuropathic and neuroischemic ulcers. Because of the absence of proximal disease. typical arteriographic appearance shows the corkscrew col- laterals and absence of central atherosclerotic lesions.13 14 Ulcers associated with hematologic diseases Sickle cell disease is the commonest hematologic cause of ulceration in the feet. — absence of typical risk factors for atherosclerosis such as hyperlipidemia. polycythemia. irregular growing edge is characteristic. either primary to the skin or metastatic. The two major types of lym- 202 . — affects peripheral distal arteries and usually spares the proximal arteries.16 Miscellaneous — Pyoderma gangrenosum is usually associated with inflammatory bowel disease. There is no specific blood test to confirm the diag- nosis. The commonest venous manifestation is thrombophlebitis migrans. — always associated with heavy smoking and usually in young men. and vibration sense Variable sensory findings Increase in blood flow (AV shunting) Decrease in blood flow Dilated veins Collapsed veins Dry. It begins as papules. Almost any type of malignant tumor. but no definitive cause has so far been established.

1975. Leg ulcers in patients with sickle cell disease.46:491-499. References 1. Young JR. Dore CJ. BMJ 1979. Koranda A. Rutherford RB. Mills JL. Entsuah R. Hospital admissions of diabetic patients. Microangiopathy in the context of diabetic foot problems: fiction or fact? VASA 1992. Lancet 1993. In: Rutherford RB. Aetiology of chronic leg ulcers. Drucker WR.342:1012-1016. Reynen HM. Stacey MC. Roenigk HH.6:245-251. Buerger’s disease. 13. Veldman PH. 14. Vasc Med Review 1994. Pathogenesis of posttraumatic sympathetic dystrophy. 7. Archer AG. Mastalgia F.24:59-63. Leg ulcers: epidemiology and etiology. Hoskin SE.2:27-32. The natural history of acute painful neuropathy in diabetes mel- litus. 11. Sharma AK. 5. Thomas PK. Eur J Vasc Surg 1992. Baker SR.2:424-432. 12. Philadel- phia: Saunders. 15. 8. Singh G. Stieglerh. Moore WS. Itin PH. 16. J Neurol Neurosurg Psychiatry 1983. et al. Standle. Am J Surg 1959.1:663-666.73:693-696. Diabet Med 1985. Winkelmann RK. Drug induced peripheral neuropathies. Causalgia and other post-traumatic pain syndromes. 203 .3% of patients with diabetes. BMJ 1995. 4th ed. Leg Ulcers: Medical and Surgical Management. 10. Heart Dis Stroke 1993. 3. Williams DR. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Cutaneous manifestations in patients with essential thrombocythemia. Argor Z. Buergerís disease: current status. 6.35:25- 26. 4. Paice E. Holden WD. Lewis JD. Koshy M. et al.5:139-150.310:1645-1648. ed. Vascular Surgery. 1995:736-740. Callam MJ. Fowkes F. Watkins PJ. Hagerstown. Is arterial disease a risk factor for chronic leg ulceration? Phlebology1994. — Necrobiosis lipoidica is found in approximately 0. phoma causing leg ulceration are mycosis fungoides and lymphosarcoma. et al. Thompson PJ.9:87-90. J Am Acad Dermatol 1991. Cornwall JV. Arntz IE. 9. Colburn MD. Payan J. Br J Surg 1986.97:454.74:1403-1408. Information from hospital activity analysis. 2. MD: Harper Row Publications. Hildebrandt. Blood 1989. Reflex sympathetic dystrophy. Hubay CA.