MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

Vascular occlusion: Toe gangrene and toe ulcer

Peripheral vascular disease
 Common problems: leg pain, ulcer, gangrene in foot

Anatomy of peripheral vascular system

 Superficial femoral artery
o How it runs (main artery)
 Internal iliac: 10 branches

1. Acute occlusion (management – common OSCE questions)

 Causes (underlying cause: atrial fibrillation)
o Embolism (lodge in bifurcation)
o Thrombosis (pre-existing arterial disease, sudden thrombosis)
o Trauma (uncommon in HK, injury to legs, traffic accidents, supra-condylic
fracture)  recognise signs of ischemia  arteriography if in doubt!
 No time for collaterals to develop, thus would lose the leg really quickly
  SURGICAL EMERGENCY (would not usually see in wards)
 Clinical symptoms (6Ps)
o Pain (usually sudden onset)
o Paresthesia (ischemic nerve)
o Pallor
o Pulseless (leg pain – always feel for pulse  acute arterial insufficiency)
o Paralysis (nerve and muscle paralysed)
o Perishing cold
 E.g. acute aortic thrombosis (delayed)
o Advanced colour changes, leg is probably dead (no gangrene, no ulcers)
o Advanced mottling
 Treatment
o Surgery: Fogarty embolectomy catheter (6 hours)
o Diagnosis: clinical (NOT arteriogram)
 Commonly have atrial fibrillation as a clue
o Anti-coagulation
 Heparin (prevent more clot formation)
o Surgery – embolectomy (prevent tissue loss – emergency)
 Fogarty catheter
 Small cut in the artery  catheter in distal part  retrieve the
clot  pull out of the artery
 Performed under anesthesia
 Thrombolysis (very sick patients)
 Complication: compartment syndrome
o With re-perfusion  blood goes down to the legs  swelling, cells are injured
(would not be able to maintain homeostasis  fluid into the cells)
o Muscles can be swollen  squeeze themselves to death
o Perform fasciotomy (cuts in the fascia)
o Helps relieve the pressure
o Swelling subside  close the wound after
 Complication: electrolytes/renal failure
o Passing of dark urine
o Need enough fluid to flush
 Identify source of emboli (cardiologist referral)
MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

o ECHO

2. Chronic occlusion
 Gradually reducing blood flow to the legs
 Causes
o Atherosclerosis (all parts of the body)
o Vasculitis
o Entrapment
 Risk factors
o Smoking
o Diabetes mellitus
o Hypertension
o Hyperlipidemia
o Family history
 Clinical presentation
o 1. Intermittent claudication: insufficient blood supply to the muscles of
walking (no pain at rest)
 Calf/thigh (tightness during exercise)
 Muscle ischemia
 Increased demand
 Subsides with rest (differs from injury/trauma)
 Claudication distance (specific amount of exercise, e.g. 300m)
o 2. Rest pain (severe occlusion, collaterals are not enough to sustain basal
metabolic conditions of the leg)
 Toe/forefoot, NOT in calf (furthest away from the supply)
 Ischemia of skin and subcutaneous tissue (nerve ending is not receiving
blood; vs muscles which are well supplied with blood)  colour
changes  tissue loss
 Pain at rest
 Improves on dependency (gravity pulls blood into the foot; hangs foot
on the side of the bed)
 Critical ischemia (foot will die if do not intervene)
 NOT a severe form of claudication, a new symptom
o 3. Tissue loss
 Ulcers (painful)
 Resting pain in toes
 Gangrene (toes die)
 Dry (no infection):
o NOT a surgical emergency  can be treated by proper
investigation and devascularize the foot
o Well demarcated
o Extend proximally
 Wet (infection):
o Demarcation is less clear
o Foul smelling gas formation
o Formation of fluids
o Foot threatening and life threatening (spread of
infection)
 Location: pressure areas since pressure stops capillary blood
flow (heels, toes, end of metatarsal bones)
MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

 Clinical evaluation
o 1. Does the patient have arterial disease?
 1. Claudication
 2. Resting pain
 3. Tissue loss
 NOT swelling
o 2. Acute or chronic?
o 3. How severe?
 Claudication is not “bad”, vs gangrene/tissue loss
o 4. Where is the obstruction?
 Physical examination
 Imaging
o 5. Why?
 Risk factors of atherosclerosis  a systemic disease
 Major levels of arterial occlusion
o Proximal: aortoiliac (femoral pulse)
 Features
 Large vessels
 Claudication (thigh, calf)
 Impotence
 Above inguinal ligament (aorta)
 Better outlook  more collaterals (claudication in buttocks, thigh
and legs)
o Middle: femoro-popliteal (popliteal pulse)
 Features
 Claudication (calf)
 Tissue loss
 In between proximal and distal occlusion
o Distal: (dorsalis pedis pulse)
 Features
 Small vessels
 Tissue loss
 Below the knee, diabetic patients
 End arteries, small arteries  less collaterals  poorer
prognosis (difficult to treat)
o *Examine one pulse: feel the femoral (would not miss)  would have proximal
arterial disease
o *Proximal vessels: claudication; Distal vessels: tissue loss and gangrene
 Assessment of lower limb ischemia: 1. Patient, 2. Limb
MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

o Patient has claudication  may not always need to be treated

 Investigations
o Vascular laboratory
 Ultrasound based diagnostic tool
 Detect blood flow via Doppler principle
 Indicates velocity waveform (normal: triphasic)
 Help locate the claudication
 Ankle-brachial index: blood pressure cuff at the ankle, and at arm
 Ankle systolic pressure/arm systolic pressure = 1
 <1 (obstruction in lower limbs)
o Assess severity
o Monitoring

 Pressure measurement
 *Principle is similar to measuring the presence of pulse, but
pressure measurement gives a numerical reading and waveform
 Assess
o Pressure
o Waveforms
MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

 Normal: triphasic (systole  diastole during

resistance)
 Abnormal: monophasic
 Locations of measurement
o Aortoiliac
o Femoro-popliteal
o Distal
 Treadmill exercise
 Measure ankle brachial index before and after
 Stays the same  not intermittent claudication
 Will fall if there is intermittent claudication  muscles take the
blood

o Arteriography
 Indication: surgery is planned
 Rarely use CT angiogram/MRI angiogram
MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

Popliteal artery branches:

1. Anterior tibial (lateral)
2. Posterior tibial (medial)
3. Peroneal (between ant. and post. tibial, does not go down)
MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

 CT angiogram is usually NOT necessary, additionally its limitation is that if arteries are
calcified, do not know if it is calcium deposition vs artery occlusion; additional
radiation; expensive as well
 Treatment of intermittent claudication (chronic arterial diseases)

o 1. Improve survival
 Risk factor modification
 Smoking cessation
 Diabetes control
 Lipid lowering therapy
 Hypertension control
 Drugs (to prevent cardiovascular risks)
 Anti-platelet agents (aspirin, anti-platelet)
o 2. Improve symptoms
MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

 1. Exercise
 Walk everyday under supervision ideally (until have
claudication  stop  repeated)
 Improve utilization of oxygen, maximizing the use of oxygen in
the leg (around 50% pateints improve)
 2. Drugs
 i. Pletaal (Cilostazol) (most common) (evidence)
 ii. Praxilene (Nafidrofuryl)
 iii. Trental (Pentoxyphylline)
 Functions: Anti-platelet, anti-oxidant, vasodilatation
 Side effects: headaches, not ideal for poor cardiac function
 3. Surgery
 Indications for surgery
o 1. Disabling claudication
o 2. Limb salvage (resting pain, gangrene, tissue
ulceration): critical ischemia
 *Never amputate the digits before revascularize  because to
heal the wound, need extra blood supply (thus, convert dry
gangrenous into wet – infective potential  become non-
healing wounds)
 *Amputate AFTER revascularization surgery  better healing
 * Keep the vessel open for sufficient amount of time for wound
to heal
o Lesser procedure, with higher failure rates
o Care about 3-6 months of patency  to save the
patient’s foot
 Choice and assessment
o Endovascular vs open surgery
o TASC II: degree of stenosis and length of stenosis (do
not memorize)
 Types of surgery
o Endarterectomy (local procedure) (less common)
 Indications: larger vessels, short segments,
stenosis (e.g. iliac, carotid)
 Clamp on arteries  dig out the atheroma of the
occlusion, close the artery
 Removal of intima of the artery  improve blood
flow
o Arterial bypass
 Inflow  obstruction  outflow (runoff)
 Named by the inflow artery-outflow artery
 E.g. aorto-iliac, aorto-femoral, femoro-
popliteal
 E.g. femoro-femoral, axillo-femoral
 Classification
 Anatomical: route is the normal blood
flow pathway
 Extra-anatomical: extra channel of flow
o Grafts: prosthetic grafts
 Indications: aorta, open abdominal wound,
bypass graft
MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

 Femoro-popliteal bypass: Reverse the vein 

connect the vein from one side to the other side
 Femoro-anterior tibial bypass: bigger wounds,
good results
 Femoro-femoral bypass: instead of doing aorta
procedure (esp. for elderly patients)
 Axillo-bifemoral bypass  cross over to supply
both legs (extra-anatomical)
MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

o Balloon angioplasty
 Guidewire  blood up the balloon  press
plaques on the side  metallic stent (prevent
elastic recoil) = hold intima and plaque on the
side of the wall
 Short segment stenosis is best, e.g. iliac artery
 Advantages
 Low risk
 Repeatable
 Short recovery (unless gangrene toes)
 Cost (relatively low)
 Low morbidity/mortality
 More acceptable for older patients (80s,
90s  do not do well for bypass
operations)
 Limitations
 Durability (do not last as long as open
surgery – the stent) – long stenosis,
occlusions
o Iliac arteries angioplasty: bigger 90%
in 3 year patency
o Femoral arteries or below: smaller,
long segment, occlusion, recurrence
of plaque, 60% in 3 years patency
 Stents (do not improve patency): not a
long term procedure
 Brachytherapy/drugs
o Adjuncts
 Laster, cryoplasty, drug eluting stents, drug
eluting balloons, rotation atherectomy  new
and expensive prpducts  enable surgeons to
get better result of endovascular intervention;
dependent on the market
  Amputations: cut off gangrene (balance risks and choices)
o Types:
 Below knee amputation
 Long posterior flap (blood supply
posteriorly is better)
 Mobility is much better
 Younger patient: try to do below knee
amputation
 Blood supply below the knee is not good
 stump necrosis (cut off more leg)
 Above knee amputation
 Better blood supply
 Patient who cannot walk again anyways;
estimated need 70% more energy 
patient will not walk again
 Achieve wound healing, best chance of
healing
MBBS IV WCS 002 – Vascular occlusion (toe gangrene and toe ulcer)

3. Buerger’s disease (thromboangitis obliterans)

 Young man, 40 y/o (vs old – atherosclerosis)
 Clinical features
o Pan-arteritis
o Medium and small sized arteries and veins
o Lower limb > upper limbs
o  Rest pain, digital ulcers, gangrene (toes and fingertips)
o Arteriogram “tree trunk”
 Pathophysiology
o Inflammatory, autoimmune disease
o Inflammation of medium and small size arteries of veins
o Thickening of walls
o Obliteration of vessels
o Veins are affected as well
 Treatment
o Reconstruction rarely possible
o Smoking cessation

Common pitfalls
 Mis-diagnosis of claudication
o Specific symptoms, onset, history
 Toe amputation before revascularization (unless emergency/infection)
 Misuse of CTA/MRA
 Delay recognition of acute ischemia (6Ps, limited window to treat patient)
 Beware of “leg pain”: many other conditions
 “Treating the angiogram” – intervention for asymptomatic disease