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174
Manipal Manual of Surgery
Key Box 26.16
Skin Care
1. Regular, periodical skin inspection, especially over the
bony prominences.
. Any sign of redness, irritation or abrasion—if noted—
2
all pressure must be taken off the area immediately.
3. Keeping the skin clean and dry: Moist areas lead to
maceration. Fine talcum powder may be applied to
areas where moisture tends to develop. It must be
dusted every day after drying the skin.
4. Gentle massage of vulnerable skin with lanolin lotion.
5. Care of perineum and genitalia, especially in patients
with incontinence.
6. Clothing and bedding must be wrinkle-free, made of
porous absorbent material to allow air circulation and
avoid accumulation of perspiration.
7. Pressure relief—in bedridden patients.
a. Frequent change of posture round the clock every
2 hours.
b. Avoid localised pressure by proper body alignment.
c. Use of air or fluid-filled floatation mattresses also
lessens risk of ulcer formation.
d. Patient and patient’s family education.
Treatment
1. Superficial ulceration: Debridement and allowing it
to heal by secondary intention (takes many weeks)
2
. Deep ulceration or large superficial ulceration
• Bedside debridement of obviously necrotic material
• ‘Wet to dry’ dressing
• Use of desloughing agents
• Systemic antibiotics
• Nutritional consideration
• Correction of spasm and contractures, if present
• Once it is ready, the defect is closed
Methods of closure
. Primary closure—undermine and approximate the
a
cut edges
b. SSG—in selected cases only
c. Skin flaps
• Transposition flap
• Rotation flap
• Advancement flap
d. Cultured muscle interposition for severe and
ischial pressure sores.
. Education of the patient and patient attenders to
3
prevent pressure sores.
Miscellaneous
Maggot Therapy
• A maggot is the larva of
a fly, such as house fly.
In practice, any neglected
wound on the body, especially over the legs, may
get contaminated with
maggots. Within 1–2 days,
there may be a colony of
maggots (Fig. 26.42).
• It is a type of biotherapy
Fig. 26.42: Maggots in diabetic
patient who had venous ulcer
involving the introduction of live, disinfected maggots into nonhealing
wounds.
• The ugly look and feeling of a crawling creature
on the body drives the patient to reach the hospital
in our country. Maggots may be removed
by using
turpentine.
• Mode of action:
Debride wounds by dissolving necrotic, infected
–
tissue.
– Disinfection of the wound by killing bacteria and
healing—doubtful.
– Maggot therapy may also reduce the need for anti-
biotics in people with complex, chronic wounds.
– Maggot therapy has been shown to accelerate the
debridement of necrotic wounds.
Indications
• Maggots inhibit and destroy a wide range of
pathogenic bacteria including methicillin-resistant
Staphylococcus aureus (MRSA), group A and B streptococci, and gram-positive aerobic and anaerobic
strains. Maggot therapy, therefore, represents a costeffective method for managing MRSA infection.
• Maggot therapy may also reduce the need for anti-
biotics in people with complex, chronic wounds.
DIABETIC FOOT ULCER AND RESEARCH
Aldose reductase is the first enzyme in the sorbitolaldose reductase pathway responsible for the reduction
of glucose to sorbitol, as well as the reduction of
galactose to galactitol. Too much sorbitol trapped in the
retinal cells, lens cells, and the Schwann cells may
damage them, leading to retinopathy, cataracts, and
peripheral neuropathy, respectively. Aldose reductase
inhibitors are currently being investigated as a way to
prevent or delay these complications.
Section II • General Surgery
Differential Diagnosis of Leg Ulcer and Pressure Sore
175
1. Which of the following statements about tubercular
ulcers is false?
A. Undermined edge
. Edge is thin and bluish in colour
B
C. Apple jelly granulation tissue
D. Wash leather slough
2. The following are true for squamous cell carcinoma
except:
A. Keratin pearls are diagnostic
. Induration at the base is significant
B
C. Ulcers have everted edges
D. Keratoacanthoma has totally different cytological
features than squamous cell carcinoma
3. The following are features of a healing ulcer except:
A. Serous discharge
. Sloping edge
B
C. Slough is absent
D. Signs of inflammation are present
4. The following are true for induration except:
A. Maximum induration is seen in malignant
melanoma
B
. Brawny induration is seen in chronic abscess
C. Carcinoma tongue may present as an indurated
lesion
D. It is overgrowth of fibrous tissue
5. Gummatous ulcer has the following features except:
A. Commonly seen in the subcutaneous tissues
. Floor has wash leather slough
B
C. Healing results in a hypertrophic scar
D. It has punched out edges
6. Alginate wound dressing has the following advantages
except:
A. Non-adherent
. Absorbs exudate
B
C. It is safe in renal failure cases
D. With silver, it may act against MRSA also
7. The characteristic feature of a venous ulcer in the
leg is:
A. Deep and painful
. Superficial with surrounding pigmentation
B
C. Penetrating with visible bone
D. Present on the dorsum of the foot
8. The following are true regarding the usage of plateletderived growth factors in wound dressings except:
A. They are used when vascularity is poor
. They are used in neuropathic ulcers
B
C. They act through tyrosine kinase receptors
D. They stimulate angiogenesis
9. The following are true for a tropical ulcer except:
A. It is caused by Vincent’s organisms
B
. Minimal inflammation
C. It is also an example of phagedenic ulcer
D. Metronidazole is helpful
10. The following are true about sorbitol except:
A. Nerve damage in diabetic foot ulcer is due to
sorbitol
B. It results from the reduction of glucose
C. It occurs when the hydroxyl group is changed to
aldehyde
D. It may be used as a laxative
11. The following are true for infrainguinal bypass
surgery for diabetic ulcer except:
A. Long saphenous vein is inferior to PTFE graft
. Preoperative vein marking is helpful
B
C. 2-year patency is around 70%
D. Amputation rate after surgery is still high
12. The following are true for cilostazol except:
A. It reduces the pain of intermittent claudication
B
. It is a phosphodiesterase inhibitor
C. Its action is similar to pentoxyphylline
D. Dose is 50 mg twice daily
Answers
1. D 2. D 3. D 4. A 5. C 6. C 7. B 8. A 9. B 10. C
11. A 12. C
Section II • General Surgery
27
Lower Limb Ischaemia and
Popliteal Aneurysm
Causes of lower limb ischaemia
Collateral circulation
Symptoms
Fontaine classification
Clinical examination
Differential diagnosis
Management
Acute arterial occlusion
SU27.1: Describe the etiopathogenesis, clinical features,
investigations and principles of treatment of occlusive
arterial disease.
INTRODUCTION
Walking is a fundamental human requirement.
Peripheral arterial disease (PAD) is a main cause of
disability. Many individuals are conscious about chest
pain caused by myocardial ischaemia and arrive at a
hospital early. However, patients present relatively late
to the hospital with lower limb ischaemia (Figs 27.1 and
27.2). The disease, though benign, is not totally curable,
causing financial, social, and psychological burden to
the patient and his/her relatives.
Critical limb ischaemia
Peripheral aneurysm
Ainhum
Frostbite
Reperfusion injuries
Fat embolism, air embolism
ICU gangrene
Fig. 27.1: Atherosclerosis
with diabetes resulting in wet
gangrene—toe has been
amputated
Fig. 27.2: Dry gangrene due to
atherosclerotic arterial disease—
part is dry, mummified and toe
has been amputated
CAUSES OF LOWER LIMB ISCHAEMIA (Table 27.1)
Occlusion refers to obstruction to the lumen of blood
vessel. Example being atheromatous plaques or a blood
clot, etc. Stenosis refers to abnormal narrowing of the
vessel. Other rare causes of lower limb ischaemia include
popliteal entrapment syndrome and cystic medial
degeneration. One should not forget that diabetes mellitus
is also a common cause of peripheral vascular disease
in elderly patients. While treating a patient with atherosclerotic disease, care of diabetes is equally important.
Table 27.1 Causes of lower limb ischaemia
Chronic lower Acute lower
limb ischaemia limb ischaemia
• Atherosclerosis • Acute thrombosis
• Thromboangiitis Obliterans • Acute embolism
(TAO) • Trauma to the vessels
• Collagen vascular disorders • Aneurysm
• Diabetes (diabetic foot—neuro-ischaemic foot)
176
Lower Limb Ischaemia and Popliteal Aneurysm
RISK FACTORS FOR PERIPHERAL ARTERIAL DISEASE (PAD)
• Smoking: Smoking in any form increases the risk by
almost tenfold. It is proportional to ‘pack-years’
smoked.
• Male (gender): Men are affected 10 years earlier than
women.
• Other risk factors: These include hypercholesterolemia
(>200 mg/d
l), hypertriglyceridaemia, hypercoagulable
state (polycythaemia), and hyperhomocysteinaemia.
• Known diabetes: Especially type 2 diabetes mellitus—
increases the risk by two to fourfold.
• Elderly patients between 60 and 70 years are
vulnerable.
• Raised blood pressure—hypertension.
You can remember as SMOKER
HYPERHOMOCYSTEINAEMIA
• It increases the risk of developing PAD by 7%
• Homocysteine levels >15 mmol/L
• Increased levels cause endothelial injury and lead to
vascular inflammation
• Defective gene for methylene tetrahydrofolate
reductase (MTHFR)
• Prevention is by eating foods containing B
, B9, B
6
and folate, such as potatoes, green vegetables, fish,
etc.
• It is also a strong risk for myocardial infarction in
young patients.
COLLATERAL CIRCULATION
• Collateral circulation is present in most organs.
Hence, even if a major vessel is occluded, the organ
may still survive provided collaterals are welldeveloped.
• In acute ischaemia caused by thrombus or embolism,
there is no time for collaterals to develop. This
results in gangrene of the limb in untreated cases
(Fig. 27.3).
• Chronic ischaemia caused by TAO or atherosclerosis
allows sufficient time for collaterals to develop
(Fig. 27.4). Hence, necrosis or gangrene that occurs
is minimised and the limb often survives.
SYMPTOMS
1. Pain in the limb is the chief symptom of lower limb
ischaemia. It is a severe, cramp-like pain due to
ischaemia of the muscles that is brought on mainly
by exertion, relieved by rest
, and reproducible. It is
called intermittent claudication (Key Box 27.1). The
most common site of obstruction is the superficial
Fig. 27.3: Sudden occlusion.
Embolic—no time for collaterals
to develop
Key Box 27.1
Fig. 27.4: Slow occlusion
(atherosclerotic). Collaterals
develop
Grades of intermittent
Claudication—Boyd’s classification
Grade I : The patient walks for a distance, gets the pain,
continues to walk and the pain disappears. As a
result of ischaemia, anaerobic metabolism takes
place, which produces substance P, lactic acid,
etc. These produce vasodilatation and the pain
disappears.
Grade II: The patient walks for a distance, gets the pain and
12
continues to walk with the pain. He has a limp.
Grade III: The patient walks and gets the pain. He has to
take rest. This grade indicates severe muscle
ischaemia.
In late stages: Pain at rest is due to ischaemia of nerves* in addition
to ischaemia of the muscles.
*Cry of the dying nerves, due to involvement of vasa nervosum
Pain is due to ischaemic neuropathy involving small unmyelinated
A, delta and C sensory fibres.
femoral artery which results in classical calf muscle
claudication (Key Box 27.2). Blood supply to the great
toe comes from the dorsalis pedis artery and a branch
from the medial plantar artery, a branch of posterior
tibial artery. When these are affected, it results in
instep claudication. The muscle affected is the
extensor hallucis longus.
Key Box 27.2
Superficial Femoral Artery
Stenosis or Occlusion
It is the most common cause of intermittent claudication
Usually calf muscles are affected
Does not produce life-threatening ischaemia unless
profunda femoris is involved.
Single stenosis less than 3 cm is treated by Percutaneous
Transluminal Angiography (PTA)
177
Section II • General Surgery
178
Manipal Manual of Surgery
Rest pain:1 It is an intractable type of pain usually
felt in the foot (instep), toes, etc. It is an indication of
severe ischaemia of the foot with impending
gangrene. Rest pain is increased in the night because
of reduced sympathetic drive, which in turn results
in decreased cardiac output and tissue perfusion.
Typically, a patient with rest pain sits on the bed,
holds his foot with both hands, or hangs his foot
off the bed. This gives him some kind of relief.
Rest pain is worse at night. It may lead to suicidal
tendency.
1
• Claudication distance refers to the distance a
patient is able to walk before the onset of pain. A
patient with severe claudication may not be able
to walk even a few yards.
• The site of claudication depends on the level of
arterial occlusion (Table 27.2).
• Tables 27.3 and 27.4 list other causes of pain in the
leg.
Table 27.2 Site of occlusion and claudication
Intermittent claudication in a young patient may be due to
some rare causes such as:
• Popliteal artery entrapment due to abnormal origin of the
gastrocnemius muscle
• Cyst in the media of the popliteal artery
• Hyperhomocysteinaemia
2. Nonhealing ulcer is the next commonly presenting
symptom. It is usually precipitated by minor trauma
and occurs in the most distal part of the body, such
as the tip of the toes. Ischaemic ulcers are deep and
very painful.
3. Some patients present with gangrenous patches of
skin or subcutaneous tissue (Fig. 27.5). Gangrene
affects distal parts such as toes. However, gangrene
is minimal because of collaterals.
Level of occlusion Claudication site
Aortoiliac obstruction Claudication of both gluteal
regions, thighs and calves
Iliofemoral obstruction Claudication of thigh muscles
Femoropopliteal obstruction Claudication of calf muscles
Popliteal obstruction Claudication of the foot
muscles, instep claudication
Table 27.3 Important causes of pain in the leg
Condition Aetiology Nature of pain Location
• Intermittent (arterial) Inadequate skeletal muscle Burning or cramp like Calf muscles, thigh or gluteal region.
claudication perfusion Relieved on rest
• Neurogenic Lumbosacral
claudication compression with or without paraesthesia bending over while walking
• Venous Proximal venous occlusion Bursting Engorgement during exercise
claudication (DVT) thrombosis
• Varicosity Long saphenous varicosity
Table 27.4 Pain in the leg—other causes
nerve root Diffuse radiating deep ache Pain on first step, decreased on sitting or
Diffuse aching/heaviness Decreases on walking due to calf muscles
Etiology Character of pain Location presentation
Fig. 27.5: Thromboangiitis obliterans with dry gangrene
pump
• Atheroembolism Distal embolisation—source Aching, severe Cyanosis, ischaemic changes in toes
may be in the aorta or distal foot secondary to digital or
branch of an artery occlusion
• Lymphatic disease Idiopathic, iatrogenic Localizes
or infection. feature
Pain develops secondary to
cellulitis or lymphangitis
1
Section II • General Surgery
One of our TAO patients with sleepless nights due to rest pain committed suicide by jumping from the 2nd floor of the hospital.
Site of inflammation—redness is a
Lower Limb Ischaemia and Popliteal Aneurysm
179
4. History of bilateral gluteal claudication with impotence may occur in a young patient due to a saddle
thrombus at the bifurcation of the aorta. This is called
Leriche’s syndrome, which presents as a triad of
claudication, erectile dysfunction, and decreased
distal pulses. Impotence is due to failure to achieve
an erection due to paralysis of the L1 nerve. Gluteal
claudication is confused for sciatica and many patients
are referred to the orthopaedic department. Sciatica
causes neurogenic claudication, which is present even
at rest and is aggravated by movements of the spine.
Causes of neurogenic claudication include slipped
disc, fracture vertebrae, tuberculosis of spine, etc.
5. Coldness, numbness, paraesthesia, and colour
changes indicate chronic ischaemia.
6. The majority of patients with peripheral vascular
disease are smokers. TAO occurs exclusively in male
smokers.
Cauda equina claudication or pseudoclaudication is due to
compression of cauda equina.
1
CLASSIFICATION
• Fontaine and Rutherford also categorised chronic lower
limb ischaemia into 6 different categories ranging
from asymptomatic to major tissue loss (Table 27.5).
• Claudication is classified as either mild, moderate,
or severe based on treadmill response and ankle
pressure (AP).
Mild: Completes treadmill test. AP is >50 mmHg after
exercise.
Moderate: Cannot complete treadmill test. AP after
exercise is <50 mmHg.
Severe: Resting AP <40 mmHg (cannot complete tread-
mill test).
• Normal segmental systolic arterial pressures (mmHg)
Arm 120
Upper thigh 160
Above knee 150
Below knee 140
Ankle 130
Diagnostic criteria of TAO: = Shionoya criteria
• Age at onset <50 years
• Smoking history +
• Distal extremity ischaemia, upper limb involvement,
phlebitis migrans
• Typically, infrapopliteal occlusions
SIGNS: CLINICAL EXAMINATION
Inspection
The findings are appreciated better if a comparison is
made with the opposite limb. Evidence of chronic
ischaemia of the leg includes:
• Attitude of the limb: Very often, the patient holds
the calf muscles or dorsum of the foot (Fig. 27.6).
Commonly asked question—why does the patient hold
his legs and hang them off the bed?
1. Venous stasis and reflex vasodilatation.
2. He compresses the muscles with his hands which may
also help in venous return.
3. Warmth of the hands is transferred to the limb.
These are explanations given by many experienced
senior examiners and teachers. I request student to
verify these explanations.
4. Gravity assisted blood flow.
• Flattening of the terminal pulp spaces of toes
• Fissures and cracks between the toes
Table 27.5 Clinical classification of PAOD
Fontaine Classification Rutherford Classification
Stage Clinical Grade Clinical
I Asymptomatic 0 Asymptomatic
IIa Mild claudication 1 Mild claudication
IIb Moderate to severe 2 Moderate to severe
claudication 3 Severe claudication
III Ischaemic rest pain 4 Ischaemic rest pain
IV Ulceration or gangrene 5 Minor tissue loss
6 Major tissue loss
1
A 26-year-old female, nonsmoker patient presented to the hospital with ischaemic features of the right upper limb. All causes of upper limb
ischaemia were ruled out (Raynaud’s, cervical rib, etc.). On careful questioning, she admitted to using Snuff dipping for 10 years (snuff contains
nicotine).
Section II • General Surgery
180
Fig. 27.6: Attitude of TAO patient—foot is tightly held by hand.
Observe gangrene, ulcer, skin changes and ridged nails
Manipal Manual of Surgery
• Ulceration of toes, interdigital ulcers
• Brittle, flat, and ridged nails, shiny skin
• Loss of hair and subcutaneous fat
• The limb may appear more dark in dark-skinned
patients or markedly pale in fair-skinned patients
with vasospastic diseases such as TAO.
• Gangrene is usually dry with a clear line of demarca-
tion. It indicates the junction of dead and living tissue.
Since the blood supply to the muscle is better, usually
the line of demarcation involves skin and subcuta-
neous tissue. The line of demarcation is very well
appreciated in senile gangrene, where it may be skin,
muscle, or bone-deep.
• The limb may show muscle atrophy.
• Multiple toes and finger involvement suggest
vasculitis (Fig. 27.7).
Why is ischaemic pain more in the night?
Loss of gravity assistance to arterial supply, reduction in
cardiac output at rest, reactive dilatation of skin vessels to
warmth, and increased attention of the patient to the leg.
Palpation
1. Ulcer: Examination should be done as described in
Chapter 6. Ischaemic ulcers are very tender.
2. Gangrene: It is described according to its size, shape,
and extent. In dry gangrene, the part is dry and
mummified or shrunken. Features of dry gangrene
are summarised in Key Box 27.3.
Key Box 27.3
Gangrene
Loss of temperature
Loss of pulsation
Loss of sensation
Loss of colour
Loss of function
3. Limb above
1
• Ischaemic limb is cold: Careful palpation from
above downwards will reveal the change in temperature from warm to cold. Temperature changes
are better appreciated with the dorsum of the hand
because it has many cutaneous nerve endings.
• Tenderness: It is tender due to the presence of
inflammation.
2
• Sensation: Ischaemic limb is hypersensitive
, due
to irritation of the nerve endings.
• Pitting oedema may be due to thrombophlebitis
or due to nonfunctioning of the limb.
• Feel pulses in all four limbs and in the head and
neck region.
3
4. Palpation of pulses
(Table 27.6).
• After examining the pulses, results are interpreted
in a pulse chart as shown in Key Box 27.4.
• In a similar manner, upper limb pulses and head
and neck pulses are also recorded in the pulse chart.
Key Box 27.4
Pulse Chart
(For example, classical case of TAO left lower limb)
Lower limb pulses Right Left
Dorsalis pedis ++ Posterior tibial ++ -
Popliteal ++ +
Femoral ++ ++
++ : Normal; + : Weak; – : Absent.
Fig. 27.7: Vasculitis with collagen vascular disorder. It had
affected all the ten toes
1
It is better to palpate the entire limb from the thigh downwards.
2
Ischaemic limb is like irritable personalities.
3
Section II • General Surgery
A thorough clinical examination of pulses includes not only lower limb vessels but also the head, neck, and upper limb vessels
+++ : Indicates prominent pulse such as water hammer pulse as
in aortic insufficiency
Lower Limb Ischaemia and Popliteal Aneurysm
Table 27.6 Examination of peripheral vessels
Artery Site where it is felt Remarks
Examination of lower limb pulses
1. Dorsalis pedis is the At the level of ankle joint lateral In 10% of cases, it can be absent
continuation of anterior tibial artery to extensor hallucis longus. It should
not be felt distally where it dips into
the plantar space
2. Posterior tibial artery is a In between the medial malleolus and For circulation of the foot, any one of
branch of popliteal artery medial border of the tendoachilles these arteries is sufficient
3. Popliteal artery, a continuation of It is felt in the prone or supine position The knee is flexed to relax popliteal
femoral artery, extends from the with knee flexed. It is felt against lower fascia. Dorsalis pedis, posterior tibial
hiatus in adductor magnus to the end of femur or against tibial condyles and popliteal artery are usually not
fibrous arch in soleus. It is about palpable in TAO patients
20 cm long
4. Femoral artery is the continuation It is felt midway between anterior superior Abduction and external rotation of the
of external iliac artery iliac spine and pubic tubercle, just below hip joint may facilitate the palpation in
the inguinal ligament in the upper thigh obese patients
Examination of head and neck vessels
1. Subclavian artery arises from It is felt in the supraclavicular region in Difficult to feel in obese patients
the arch of aorta on the left side the posterior triangle against the first rib
and brachiocephalic on the right side
2. Common carotid artery arises from It is felt against the carotid tubercle of Carotid artery bifurcates at the upper
arch of aorta on the left side and sixth cervical vertebra (C6) in the carotid border of the lamina of thyroid cartilage
from brachiocephalic artery on the triangle (at the upper border of the (C3 vertebra)
right side thyroid cartilage)
3. Superficial temporal artery is It is felt in front of tragus of the ear This is involved in temporal arteritis, a
the terminal branch of the external against the zygoma type of giant cell arteritis
carotid artery
181
Disappearing pulse: When collateral circulation is very
good, peripheral pulses may be normal. However, when
the patient is asked to exercise, the pulse may disappear.
Exercise produces vasodilatation below the obstruction
and arterial inflow cannot keep pace with the increasing
vascular space. Hence, the pressure falls and the pulse
disappears.
Other Tests of Minor Importance
Buerger’s postural test is relevant in fair-skinned
1.
patients. The patient (supine) is asked to raise his legs
vertically upwards keeping the knees straight. In
cases of chronic ischaemia, marked pallor develops
within 2–3 minutes. The angle at which pallor develops is Buerger’s angle of circulatory insufficiency.
In an ischaemic limb, pallor develops even on
elevation of the leg by 15–30°.
2. Capillary refill test: Apply pressure over the tip of
the terminal pulp space for a few seconds and release
the pressure. Rapid return of circulation is observed
in normal persons (<2 seconds). The test may also be
done in the ischaemic foot by asking the patient to
sit up and hang his legs down and observing for
colour changes. The time taken for the ischaemic foot
to become pink is described as the capillary filling
time. This is prolonged in an ischaemic foot.
Quincke’s sign is pulsation of the capillary nail bed that occurs
in cases of aortic regurgitation with a very wide pulse pressure.
Auscultation (Figs 27.8 and 27.9)
1. Systolic bruit over the femoral artery may be heard
in atherosclerotic occlusion of the iliofemoral segment
due to turbulence created by the blood flow.
2. Auscultation of the heart to rule out mitral stenosis
(mid-diastolic murmur, loud S1).
An 18-year-old girl was kept in the MBBS examination
with ischaemia of the lower limb of 6 days duration. A
candidate offered collagen vascular disorder as the first
diagnosis and failed.
He had totally missed the cardiac history and findings by
not auscultating the heart. It was a case of mitral stenosis
with acute embolic gangrene of the lower limb.
Section II • General Surgery
182
Fig. 27.8: Auscultation of the heart
to rule out valvular heart diseases
Manipal Manual of Surgery
Fig. 27.9: Auscultation over the
femoral artery to look for bruit
DIFFERENTIAL DIAGNOSIS
• Even though there are many causes of lower limb
ischaemia, thromboangiitis obliterans (TAO) and
atherosclerotic vascular disease are the most common
causes. Hence, they should be considered before
giving other diagnoses.
• TAO is also called Buerger’s disease. The details are
given in Table 27.7 and Key Boxes 27.5–27.7.
• Atherosclerotic vascular disease is the most common
cause of lower limb ischaemia. It may manifest from
a simple ulcer to massive gangrene.
Table 27.7 Differential diagnosis
1. Age 20–40 years Around 50 years and above
2. Sex Exclusively males Females are also affected
3. Aetiology 1. It is a smoker’s disease. Excessive tobacco 1. Atherosclerosis is a rich man’s disease,
4. Pathology Diffuse inflammatory reaction involving all three Deposition of lipid-rich atheromatous plaque
5. Vessels involved Small- and medium-sized vessels such as Medium-sized and large vessels such as
6. Upper limb involvement Not uncommon Rare
7. Nature of vessel wall Not thickened Thickened
8. Blood pressure Normal in the normal limb and low in Hypertension is commonly present.
9. Superficial
thrombophlebitis of lower limb are involved and are tender
10. Raynaud’s phenomenon Can be present Not seen
11. Auscultation—femoral Bruit is not heard. Bruit can be present as in aortoiliac disease.
artery
12. Angiography Cork-screw pattern of vessels Shows site of block
2
migrating Seen in about 30% of cases of TAO. Veins Not seen
1
TAO (Buerger’s disease) Atherosclerosis
(nicotine) produces severe vasospasm who is usually a smoker, diabetic and
of the vessels. hypertensive.
2. Excessive smoking produces increased 2. Strong family history is also present in a
levels of carboxyhaemoglobin which few cases.
damages these vessels.
3. Low socioeconomic group, recurrent 3. Consumption of high fat diet leading to
trauma to the foot, poor hygiene are obesity, lack of regular exercises and
additional factors. hypercholesterolaemia are other factors.
4. Hypercoagulable state
5. Autonomic hyperactivity
6. Autoimmune factors
coats of vessel (panarteritis) causing a in the intima is the hallmark of
thrombus, resulting in occlusion of lumen atherosclerosis. Plaques tend to be more in
(obliterans). Polymorphs, giant cells and lower abdominal aorta, coronary arteries,
micro-abscesses are found within the etc. Plaques may undergo calcification,
thrombus. In severe cases, vein and nerve ulceration and thrombosis, dislodge
are bound by fibrous tissue. cholesterol emboli or may weaken the media
and produce aneurysm.
dorsalis pedis, posterior tibial, popliteal are aorta, common iliac, femoral, common
commonly involved. carotid arteries are involved.
diseased limb.
and thickened.
1
From MBBS examination point of view, TAO and atherosclerotic vascular disease are to be differentiated.
2
Section II • General Surgery
Migrating thrombophlebitis is also seen in pancreatic malignancy where it is called Trousseau’s sign.
Lower Limb Ischaemia and Popliteal Aneurysm
183
Key Box 27.5
Checklist of Features of Chronic
Lower Limb Arterial Occlusion
Cold and numbness
Limb elevation: Slow venous refilling. Line of demarca-
tion present
Altered/diminished sensation
Ulcerations
Dead toe—gangrene—dried and mummified
Intractable pain—rest pain
Cracks, fissure—interdigital
Arterial pulsations decreased or absent
Thrill/bruit may be present
Intermittent claudication
Oedema—if thrombophlebitis or cellulitis occurs
Narrow calf muscle girth—muscle atrophy
Remember as CLAUDICATION
Key Box 27.6
Classification of Buerger’s Disease
Type I: Upper extremity
Type II: Crural (leg and foot)
Type III: Femoral type—femoropopliteal
Type IV: Aortoiliac
Type V: Generalised type
Key Box 27.7
Buerger’s Disease—Summary
Male smoker
Progressive, nonatherosclerotic, segmental, occlusive,
inflammatory condition
Occlusion of small- and medium-sized vessels,
superficial thrombophlebitis and Raynaud’s phenomenon constitute the ‘triad’ of TAO.
Microabscesses, polymorphs, giant cells (pathology)
are found.
Distal, infrapopliteal, segmental occlusion with skip
lesions and corkscrew collaterals in angiogram.
Stop smoking
Start analgesics
Lumbar sympathectomy is of some value
Key words can be remembered as PRISON
Progressive, Inflammatory, Segmental, Occlusive,
Nonatherosclerotic
MANAGEMENT
Investigations
1. Complete blood picture: Anaemia definitely delays
wound healing and decreases tissue perfusion. High
total count indicates secondary infection.
• Elevated platelet count suggests risk of thrombosis.
• Fasting blood glucose and glycosylated haemo-
globin. HbA1c
is an important test as it reflects
the duration of diabetes.
• Increased creatinine indicates renal disease.
2. Lipids: Fasting total cholesterol, high density lipo-
protein, low-density lipoprotein, and triglyceride
concentration—hyperlipidaemia should be controlled
to prevent progression of peripheral arterial disease
and death from coronary artery diseases.
3. Hypercoagulable status:
• Protein C deficiency is identified as a risk factor
for arterial thrombosis, especially in patients who
will be treated with heparin.
• Heparin-induced platelet aggregation and heparin-
induced thrombocytopaenia.
• Antiphospholipid antibody (APLA) syndrome
(APLS) is also called Hughes syndrome. It is an
autoimmune hypercoagulable state resulting
in thrombosis of veins (deep vein thrombosis),
thrombosis of artery (stroke), and pregnancyrelated complications. It is treated by aspirin and
heparin.
• Homocysteine levels (4 to 15—normal, >15 mmol/L
can be dangerous).
4. Hand held Doppler ultrasound blood flow detector:
This is an extension of clinical examination. This
test is based on the Doppler principle. An ultrasound
signal is beamed at an artery and the reflected beam
is picked up by a receiver. Frequency changes of the
beam due to moving blood are converted into audio
signals which may be heard by a probe. Thus, a
Doppler probe may be used to detect the pulse even
when the pulse is clinically not palpable (Figs 27.10–
27.13). Using a sphygmomanometer, systolic blood
pressure (SBP) of the limb can be measured by
positioning the cuff at a suitable level and the
pressure index can be calculated. This is called ankle
brachial index (ABPI).
Ankle brachial
pressure index
Ankle blood pressure
=
Brachial blood pressure
• Normal values are >1. However, in patients with
peripheral vascular disease of the lower limb, the
values are <1 (indicative of vascular obstruction).
Section II • General Surgery