Patient with a toe gangrene coming to Emergency Department Joel Arudchelvam Atherosclerotic OAD – Risk factors Presentation FONTAINE CLASSIFICATION Rutherford classification SVS Lower Extremity Threatened Limb (WIFI) classification

1. Joel Arudchelvam
MBBS (COL), MD (SUR), MRCS (ENG)
Consultant Vascular and Transplant Surgeon

2.  65 year old male
 Blackish discoloration of the toes for 3 days
 Pain
 Ulcer with purulent discharge on plantar surface
at the base of toes
 Smoker
 Hypertension , diabetes mellitus

3.  WT done
 Pus drained
 Absent popliteal,
dorsalis pedis,
posterior tibial
(distal) pulses
 ABPI – 0.5

4.  2D Echo – EF - 55%
 SCr – 0.9 mg/dl
 PLAN
 Investigation
 Management

5.  Ischaemia
 Infection
 Trauma
 Above combination

6. Causes
 Atheromatous
 Risk Factors
 Smoking
 Diabetes
 Hypertension
 Hyperlipidemia
 Advanced age
 Inflammatory
 Others

8. • Claudication
• Rest pain
• Ulcer
• Gangrene

9.  Stage Symptoms
 I Asymptomatic
 II Intermittent claudication
 IIa Pain-free, claudication walking >200 m
 IIb Pain-free, claudication walking <200 m
 III Rest pain
 IV ulcer / gangrene
 Stage III and IV “critical limb ischaemia”

10. G
r
Ca
t
Clinical description Objective criteria
0 0 Asymptomatic Normal treadmill or reactive hyperemia
test
1 Mild claudication Completes treadmill exercise; AP after
exercise > 50 mm Hg but at least 20 mm Hg
lower than resting value
I 2 Moderate claudication Between categories 1 and 3
3 Severe claudication Cannot complete standard treadmill
exercise, and AP after exercise < 50 mm Hg
II 4 Ischemic rest pain Resting AP < 40 mm Hg, flat or barely
pulsatile ankle or metatarsal PVR;
TP < 30 mm Hg
III 5 Minor tissue loss—
nonhealing ulcer, focal
gangrene
Resting AP < 60 mm Hg, ankle or
metatarsal PVR flat or barely pulsatile;
TP < 40 mm Hg
6 Major tissue loss—
extending above TM level,
no longer salvageable
Same as above

11.  Wound
 Ischemia
 Foot Infection

12. Grade Ulcer Gangrene
0 No ulcer No gangrene
.
1
Small, shallow ulcer on distal leg or
foot; no exposed bone, unless
limited to distal phalanx
No gangrene
2
Deeper ulcer with exposed bone,
joint, or tendon; generally
not involving the heel; shallow heel
ulcer, without calcaneal involvement
Gangrenous changes limited to
digits
3
Extensive, deep ulcer involving
forefoot and/or midfoot; deep, full-
thickness heel ulcer ± calcaneal
involvement
Extensive gangrene involving
forefoot and/or midfoot; full-
thickness heel necrosis ±
calcaneal involvement

13. Grade ABI Ankle systolic pressure TP, TcPo2
0 ≥0.80 >100 mm Hg ≥60 mm Hg
1 0.6-0.79 70-100 mm Hg 40-59 mm Hg
2 0.4-0.59 50-70 mm Hg 30-39 mm Hg
3 ≤0.39 <50 mm Hg <30 mm Hg

14. Clinical manifestation of infection SVS
No symptoms or signs of infection 0
Infection present, as defined by the presence of at least two of the
following items:•Local swelling or induration•Erythema >0.5 to ≤2 cm
around the ulcer•Local tenderness or pain•Local warmth•Purulent
discharge (thick, opaque to white, or sanguineous secretion)
1
Local infection (as described above) with erythema >2 cm or involving
structures deeper than skin and subcutaneous tissues (eg, abscess,
osteomyelitis, septic arthritis, fasciitis) and no systemic inflammatory
response signs (as described below).
2
Local infection (as described above) with the signs of SIRS, as
manifested by two or more of the following:•Temperature >38°C
or <36°C•Heart rate >90 beats/min•Respiratory rate >20 breaths/min
or Paco2 <32 mm Hg•White blood cell count >12,000 or <4000
cells/mm3
or 10% immature (band) forms
3

16.  ABPI = P(Leg) / P(Arm)
 P (leg) - higher systolic blood pressure of dorsalis pedis or posterior tibial
arteries
 P (Arm) - highest of the left and right arm brachial systolic blood pressure
 ABPI < 0.9 - Abnormal

17.  In symptomatic patients when
Revascularization planned
 Arterial duplex ultrasound
 CTA
 MRA
 Contrast arteriography /DSA

18.  USS + DOPPLER
 Visualise the vessels, stenosis, plaques
 Flow and its quality
 Non invasive
 Good for infrainguinal vessels
 Abdomial vessels – bowel gas

19.  USS + DOPPLER
 Triphasic flow

20.  USS + Doppler

21.  Angiography
 CT angiography
 Catheter
angiography

22. NORMAL
OCCLUDED ARTERIES
• Scan from supra
renal level to distal
foot
• Describe all arteries
• Inflow
• Out flow

24.  Contrast directly into artery
 Traumatic
 DSA – Digital subtraction angiography
 Done though a software after obtaining initial
images

25.  Duplex – triphasic flow
in CFA

26.  CTA

27.  W - 2
 I - 3
 Fi - 1
 High risk foot

28. Indications for intervention
1. Disabling claudication
2. Rest pain
3. Tissue loss
 Rutherford 4, 5, and 6 /
 Fontaine III, IV

29.  Smoking cessation
 Statin therapy
 Optimizing diabetes control (hemoglobin A1c
goal of <7.0%)
 Antiplatelet therapy with Aspirin (75-325 mg
daily)

30.  3-month trial of Cilostazol (100 mg twice daily)
to improve pain-free walking (In patients with
IC who do not have congestive heart failure )
 Trial of Pentoxifylline (400 mg thrice daily) (In
patients with IC who cannot tolerate or have
contraindications for Cilostazol )

31. • Supervised exercise program - minimum
of three times per week (30-60
min/session) for at least 12 weeks
• For patients who have undergone
revascularization -adjunctive functional
benefits

32.  Does he have a Critical limb ischemia (CLI)
 Yes

33.  First defined - 1982.1
 Intended to apply on patients without diabetes
 An ankle pressure (AP) of
 <40 mm Hg and rest pain
 <60 mm Hg and tissue necrosis
 Rutherford 4, 5, and 6 / Fontaine III, IV

34.  Diabetic patients have a varied clinical picture
due to neuropathy and sepsis

35.  Endovascular procedures is recommended
over open surgery for focal AIOD
 In all patients undergoing revascularization
assessment of CFA and correction of
hemodynamically significant stenosis is
recommended.

36.  SFA - Focal occlusive disease not involving the origin
– endo vascular.
 Surgical bypass for;
 Diffuse disease
 Extensive calcification
 Favorable anatomy for bypass ( e.g good runoff)
 Low operative risk.
 Saphenous vein is preferred conduit for infrainguinal
bypass

37.  In patients undergoing infrainguinal
endovascular intervention - aspirin and
clopidogrel for at least 30 days
 Significant graft stenosis – need reintervention
(open or endovascular) to promote long-term
patency

38. TASC II 2007: Europ J Vasc Endovasc Surg 2007:33(S1):S52
A
Endovascular
is procedure
of choice
B
Endovascular
is preferred
therapy
C
Surgery is
preferred for
good-risk
D
Surgery is
procedure of
choice

39. TASC II 2007: Europ J Vasc Endovasc Surg 2007:33(S1):S58
A
Endovascular
is procedure
of choice
D
Surgery is
procedure of
choice
B
Endovascular
is preferred
therapy
C
Surgery is
preferred for
good-risk

41. 1. Autogenous
Reversed Saphenous vein Graft ( RSVG)
2. Synthetic
PTFE
polyester(DACRON)

42.  30 day morbidity and mortality higher in
surgery
 However after 2 years bypass strategy was
associated with a significant increase in
subsequent OS and a trend towards improved
AFS.

43. Thank You