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19. Chronic Critical Limb Ischemia
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Enrico Ascher and Anil P. Hingorani
An 85-year-old male with a history of diabetes, hypertension, hypercholesterolemia, coronary artery bypass, and active tobacco use presented with a gangrenous right first toe. The patient stated that he had no history of trauma to the
area, and complained of rest pain in the foot. The patient had been in otherwise
good health since his coronary artery bypass 12 years ago. On physical examination, the patient was in no physical distress. The patient had a well-healed
median sternotomy scar. Auscultation of the heart revealed a regular rate
without any murmurs. He was obese. Abdominal examination revealed no palpable masses. The patient had bilateral femoral and popliteal pulses but no pedal
pulses. The patient had bilateral, well-healed scars from the greater saphenous
vein harvest sites. The right gangrenous toe was dry without any evidence of
infection.
Question 1
Which of the following statements regarding chronic lower-extremity ischemia are
wrong?
A. If the patient refuses any intervention, then anticoagulation alone may be
helpful.
B. The contralateral asymptomatic lower extremity should also undergo angio-
graphy as there may be severe atherosclerotic disease there as well.
C. The treatment options remain unchanged if the patient presents with only rest
pain, ischemic ulcer or claudication.
D. The patient cannot undergo revascularization without contrast arteriography as
there are no other alternatives.
The patient’s arterial duplex demonstrated moderate distal right superficial
femoral artery disease. The ankle brachial indices (ABIs) and pulse volume record-
167
168 Vascular Surgery
ings demonstrated findings consistent with moderately decreased perfusion at the
calf level and severely decreased perfusion at the ankle and transmetatarsal levels.
The cardiac review of systems was unremarkable, and a persantine thallium
obtained 6 months ago revealed no perfusion defects. Electrocardiogram (ECG),
chest X-ray and routine preoperative blood tests were normal. Venous duplex
mapping revealed inadequate veins (sclerotic and too small) in the bilateral upper
and lower extremities.
Question 2
Preoperative medications/lifestyle changes that should be added to the patient’s
regimen to reduce his overall cardiovascular risk based upon randomized prospective data include:
A. Aspirin.
B. A statin.
C. Angiotensin-converting enzyme inhibitors.
D. Tobacco cessation.
E. A beta-blocker.
Percutaneous angiogram of the right lower extremity demonstrated moderate
right distal superficial femoral artery stenosis with distal occlusion. The popliteal
appeared to be severely diseased with occlusion of the tibioperoneal artery and
proximal anterior tibial artery. The mid-anterior tibial artery reconstituted and ran
down to the dorsalis pedis artery. No other vessels appeared to be adequate.
Question 3
What type of options would you consider for this lower extremity?
A. Below-knee amputation.
B. Digital amputation.
C. Tibial bypass with expanded polytetrafluoroethylene (ePTFE) with a venous
interposition or fistula.
D. Tibial bypass with cadaveric vein.
E. Sympathectomy.
F. Chelation therapy.
G. Subintimal angioplasty
The patient underwent a successful bypass with ePTFE to the anterior tibial
artery and did stop smoking after the procedure. The patient’s toe underwent autoamputation and the rest pain has resolved. He was followed up 2 years after the procedure with a patent bypass.
Chronic Critical Limb Ischemia 169
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Question 4
What is the patient’s long-term prognosis in terms of mortality, graft patency, and
limb salvage after successful bypass?
A. The long-term mortality, patency, and limb salvage are about 20 percent and
therefore are so poor that no intervention should be made.
B. The mortality and patency are 50 percent at 4–5 years. The limb salvage is
70 percent at 4 years. If the patient has a reasonable life expectancy and functional status, he should undergo the revascularization.
C. The mortality, patency, and limb salvage rates are irrelevant in this age group.
Question 5
Which patients would you consider to be inoperable? What treatment options may
be offered to this subset of patients?
Commentary
Indications for revascularization to the tibial vessels are limited to ischemic ulcers,
gangrene, and rest pain. The long-term patency of the bypass is affected directly by
continued tobacco use, and the patient should be urged to stop smoking.
Anticoagulation plays no role as the sole management of this patient. Even though
the patient may have asymptomatic contralateral disease, there is no role for further
investigation. Angiography may be used to visualize both inflow and outflow sites.
In general, the most distal available inflow site is utilized to shorten the length of the
graft. Time-delayed imaging may be required to visualize the calf and foot arteries
because of reduced flow. The use of magnetic resonance angiography (MRA) has
proven to be beneficial in identifying patent lower-extremity arteries, particularly in
view of the recent advances in imaging software and hardware [1–3]. Finally, highresolution duplex imaging has now become a viable alternative for visualization of
inflow and outflow sites with the added advantages of cost reduction, fewer complications associated with angiography, and the ability to identify the least calcified
artery segment [4–8]. However, both MRA and duplex imaging should be used only
as preoperative imaging modalities after they have been validated at each center.
[Q1: A, B, C, D]
Increasing focus on the perioperative and long-term management of patients
with peripheral arterial disease has identified that all the factors listed in Question 2
can significantly reduce the incidence of cardiovascular events in these patients.
These data have been supported by large multicenter randomized prospective trials
[9] Therefore, it becomes incumbent on the vascular surgeon to also consider these
as part of the treatment plan when evaluating a patient with peripheral arterial
disease. [Q2: A, B, C, D, E]
Evolution of vascular surgery techniques in the past decade, combined with the
availability of an adequate venous conduit, has permitted a liberal and aggressive
approach to salvage ischemic limbs caused by advanced atherosclerosis. This
170 Vascular Surgery
approach is epitomized by the construction of arterial bypasses to the terminal
branches of tibial vessels [10]. However, significant numbers of patients continue to
face the threat of a major amputation because of insufficient vein necessary to
perform a totally autogenous bypass to one of the infrapopliteal arteries. In these
cases, less durable grafts made of prosthetic material must be used if limb salvage is
to be attempted. Accordingly, several adjunctive techniques have been designed in
an attempt to improve the poor patency results achieved with prosthetic bypasses.
These include the administration of immediate and chronic anticoagulants [11], the
construction of a vein patch or cuff at the distal anastomosis to prevent occlusion
by intimal hyperplasia [12, 13], and the creation of an arteriovenous fistula to
increase graft blood flow in high-outflow-resistance systems [14, 15]. Despite initial
enthusiasm, the results using cadaveric vein have been poor and resulted in its very
limited use [16, 17]. [Q3: C] If the popliteal artery had been not as diseased, an
attempt at subintimal angioplasty with angiography or with duplex guidance may
also be considered [18, 19].
The expected long-term mortality of this patient is 24–50 percent at 4–5 years and
is due mostly to myocardial ischemia [20]. The expected patency of these techniques is 50–60 percent at 3–4 years [20–23]. The expected limb salvage rates are
70–80 percent at 3–4 years [20–23]. [Q4: B]
Based on these data, we would suggest that there is no role for amputation or
sympathectomy in this particular patient. However, if the patient had prohibitive
cardiac risks, had nonreconstructable disease, or was already so neurologically
impaired that the limb was not of any utility to the patient, then observation,
primary amputation, hyperbaric oxygen therapy or perhaps experimental protocols
involving angiogenesis factors may be in order. [Q5]
References
1. Carpenter JP, Owen RS, Baum RA, Cope C, Barker CF, Berkowitz HD, et al. Magnetic resonance
angiography of peripheral runoff vessels. J Vasc Surg 1992;16:807.
2. Cambria RP, Kaufman JA, L’Italien GJ, Gertler JP, LaMuraglia GM, Brewster DC, et al. Magnetic resonance angiography in the management of lower extremity arterial occlusive disease: a prospective
study. J Vasc Surg 1997;25:380–89.
3. Hingorani A, Ascher E, Markevich N, Kallakuri S, Hou A, Schutzer R, Yorkovich W. Magnetic resonance angiography versus duplex arteriography in patients undergoing lower extremity revascularization: which is the best replacement for contrast arteriography? J Vasc Surg. 2004;39(4):717–22.
4. Ascher E, Mazzariol F, Hingorani A, Salles-Cunha S, Gade P. The use of duplex ultrasound arterial
mapping as an alternative to conventional arteriography for primary and secondary infrapopliteal
bypasses. Am J Surg 1999;178:162–5.
5. Mazzariol F, Ascher E, Salles-Cunha SX, Gade P, Hingorani A. Values and limitations of duplex
ultrasonography as the sole imaging method of preoperative evaluation for popliteal and
infrapopliteal bypasses. Ann Vasc Surg 1999;13:1–10.
6. Mazzariol F, Ascher E, Hingorani A, Gunduz Y, Yorkovich W, Salles-Cunha S. Lower-extremity
revascularisation without preoperative contrast arteriography in 185 cases: lessons learned with
duplex ultrasound arterial mapping. Eur J Vasc Endovasc Surg 2000;19:509–15.
7. Ascher E, Markevich N, Schutzer RW, Kallakuri S, Hou A, Nahata S, et al. Duplex arteriography prior
to femoral-popliteal reconstruction in claudicants: a proposal for a new shortened protocol. Ann
Vasc Surg 2004;18(5):544–51.
8. Ascher E, Hingorani A, Markevich N, Schutzer R, Kallakuri S. Acute lower limb ischemia: the value
of duplex ultrasound arterial mapping (DUAM) as the sole preoperative imaging technique. Ann
Vasc Surg. 2003;17(3):284–9.
9. Hackam DG. Cardiovascular risk prevention in peripheral artery disease. J Vasc Surg
2005;41(6):1070–3.
Chronic Critical Limb Ischemia 171
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10. Ascer E, Veith FJ, Gupta SK. Bypasses to plantar arteries and other tibial branches: an extended
approach to limb salvage. J Vasc Surg 1988;8:434–41.
11. Flinn WR, Rohrer MJ, Yao JST, McCarthy WJ, Fahey VA, Bergan JJ. Improved long-term patency of
infragenicular polytetrafluoroethylene grafts. J Vasc Surg 1988;7:685.
12. Siegman FA. Use of the venous cuff for graft anastomosis. Surg Gynecol Obstet 1979;148:930.
13. Miller JH, Foreman RK, Ferguson L, Faris I. Interposition vein cuff for anastomosis of prosthesis to
small artery. Aust N Z J Surg 1984;54:283.
14. Dardik H, Sussman B, Ibrahim IM, Kahn M, Svoboda J, Mendes K, Dardik I. Distal arteriovenous
fistula as an adjunct to maintain arterial and graft patency for limb salvage. Surgery 1983; 94:478.
15. Ascer E, Veith FJ, White-Flores SA, Morin L, Gupta SK, Lesser ML. Intraoperative outflow resistance
as a predictor of late patency of femoropopliteal and infrapopliteal arterial bypasses. J Vasc Surg
1987;5:820.
16. Albertini JN, Barral X, Branchereau A, Favre JP, Guidicelli H, Magne JL, Magnan PE. Long-term
results of arterial allograft below-knee bypass grafts for limb salvage: a retrospective multicenter
study. J Vasc Surg 2000;31:426–35.
17. Harris L, O’Brien-Irr M, Ricotta JJ. Long-term assessment of cryopreserved vein bypass grafting
success. J Vasc Surg 2001;33:528–32.
18. Hingorani A, Ascher E, Markevich N, Yorkovich W, Schutzer R, Hou A, et al. The role of the
endovascular surgeon for lower extremity ischemia. Acta Chir Belg 2004;104(5):527–31.
19. Ascher E, Marks NA, Schutzer RW, Hingorani AP. Duplex-guided balloon angioplasty and stenting
for arterial occlusive disease: an alternative in patients with renal insufficiency. J Vasc Surg (in
press).
20. Neville R, Tempesta B, Sidway A. Tibial bypass for limb salvage using polytetrafluoroethylene and a
distal vein patch. J Vasc Surg 2001;33:266.
21. Ascher E, Gennaro M, Pollina RM, Ivanov M, Yorkovich WR, Ivanov M, Lorensen E. Complementary
distal arteriovenous fistula and deep vein interposition: a five-year experience with a new technique
to improve infrapopliteal prosthetic bypass patency. J Vasc Surg 1996;24:134–43.
22. Kreienberg PB, Darling RC 3rd, Chang BB, Paty PS, Lloyd WE, Shah DM. Adjunctive techniques to
improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs. J Vasc Surg 2000;31:696.
23. Hingorani AP, Ascher E, Markevich N, Schutzer RW, Mutyala M, Nahata S, et al. A ten-year experience with complementary distal arteriovenous fistula and deep vein interposition for infrapopliteal
prosthetic bypasses. J Vasc Endovasc Surg (in press).
20. Popliteal Artery Entrapment
Luca di Marzo and Norman M. Rich
A 26-year-old female presented with a 6-year history of cold foot, paraesthesia
and cramping in both legs after intensive physical training. She was a recreational bodybuilder and complained of her symptoms mostly after sporting
activity. Symptoms subsequently became more severe, with cramping requiring
20 minutes to release after sport.
Question 1
What is the presentation of cases with popliteal artery entrapment?
A. The patient is often sporty with muscular calves.
B. The patient often complains of rest pain or necrosis.
C. The patient often complains of mild symptoms with paraesthesia, cold foot and
cramping after intensive physical training.
D. Venous complaints are often encountered.
E. Symptoms due to arterial embolisation are often present.
The patient smoked 20 cigarettes a day. Her past medical history included pancreatitis when she was 12 years old and tonsillectomy when she was 19 years old. On
physical examination, she appeared healthy, with both legs appearing athletic.
Lower-limb pulses were normal, but bilateral pedal pulse reduction was noted after
calf muscle contraction. A popliteal artery entrapment (PAE) was therefore suspected, and the patient was sent for noninvasive vascular evaluation. Doppler and
colour Doppler showed normal posterior tibial and popliteal recordings, with signal
disappearance on both legs during calf muscle contraction. Doppler examination
was conducted with the patient supine recording the posterior tibial artery during
manoeuvre (Fig. 20.1). Colour Doppler was performed, with the patient prone, and
the sample volume placed in the popliteal artery. Muscular contraction of the calves
showed an arterial occlusion on colour flow imaging (Fig. 20.2).
173
174 Vascular Surgery
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Fig. 20.1.
Fig. 20.2.
Continuous-wave Doppler recording the posterior tibial artery during manoeuvre.
Colour Doppler during muscular contraction of the calves, showing arterial occlusion.
Diagnosis of bilateral PAE was made. Arteriography was conducted to confirm
the diagnosis: it showed normal popliteal arteries, with right severe stenosis and left
occlusion during calf muscle contraction (Fig. 20.3). Magnetic resonance angiography (MRA) was attempted, which demonstrated bilateral popliteal occlusion during
manoeuvre (Fig. 20.4).
Question 2
How will you make the diagnosis of PAE?
A. Doppler can detect PAE.
B. Arteriography is only carried out preoperatively to confirm results of ultrasound
scans.
C. MRA may be diagnostic in the hands of an experienced practitioner.
D. Duplex scanning can detect PAE.
E. Computed tomography (CT) scanning can detect PAE.
Popliteal Artery Entrapment 175
Manoeuvre
Fig. 20.3.
calf muscle contraction.
Arteriography showing normal popliteal arteries, with right severe stenosis and left occlusion during
Question 3
Which of the following statements regarding angiograms of a patient with PAE are
correct?
A. Normal angiograms at rest are often encountered in entrapments.
B. The angiograms show an occlusion or severe stenosis during calf muscles
contractions.
C. Three-vessel run-off is often encountered in PAE.
D. An arterial occlusion is encountered in PAE diagnosed at a late stage.
E. A post-stenotic aneurysm may be encountered.
176 Vascular Surgery
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Manoeuvre
Fig. 20.4.
The patient was considered for bilateral surgical treatment. A posterior approach
to the popliteal fussa was made through a Z-shaped incision. The medial gastrocnemius muscle had a large accessory head with a lateral and cranial insertion, causing
bilateral compression of the popliteal artery and vein. This head was resected on
both legs, without any need for muscular reconstruction.
MRA demonstrating bilateral popliteal occlusion during manoeuvre.
Question 4
Which of the following statements regarding the treatment of PAE are correct?
A. Musculotendineous sectioning is the treatment of choice in patients with a
normal popliteal artery.
B. Vascular reconstruction should be limited to cases with stable arterial
impairment.
C. If vascular reconstruction is planned, then the use of autologous vein is
mandatory.
D. The posterior approach is recommended to expose all the structures causing
compression.
Popliteal Artery Entrapment 177
E. The structure causing PAE must be sectioned completely, as incomplete sectioning
may cause recurrence.
Question 5
Which of the following statements regarding the incidence of entrapment are
correct?
A. The medial gastrocnemius muscle is involved in almost 80 per cent of cases of
PAE.
B. Venous entrapment is described more often than arterial entrapment.
C. Venous entrapment is concomitant in 20 per cent of cases of PAE.
D. More than one structure may be the cause of arterial entrapment.
E. Classification of arterial entrapment includes 12 different types.
The postoperative course was uneventful and the patient was discharged 5 days
after surgery, returning back to normal activity after 3 weeks. Follow-up demonstrated complete regression of symptoms. Ultrasound examinations (Doppler and
colour Doppler) showed normal popliteal flow with negative response to PAE
manoeuvres 1 month after surgery. The patient is now doing sport (swimming)
again without any further complaints.
Commentary
The first case of PAE was treated surgically in 1959 in a 12-year-old boy
complaining of claudication after walking 300 m. At surgical exploration,
Hamming [1] at Leyden University in The Netherlands found an occluded artery
with an anomalous course medial to the medial gastrocnemius muscle. He
transected the muscle and performed a successful popliteal artery thromboendarterectomy.
A previous description of the disease was reported in 1879 by Stuart [2], a
medical student at the University of Edinburgh. During the dissection of an amputated leg of a 64-year-old man, he observed the popliteal artery coursing around the
medial head of the gastrocnemius muscle and aneurysmal changes in the popliteal
artery distal to the point of external muscular compression.
Since than, many case reports have been published. A few authors have published
small series [3–6]. Unfortunately, the papers that were collected were missing
details and showed poor patient follow-up [7].
In Rome in 1998, the Popliteal Vascular Entrapment Forum was founded.
Surgeons from around the world with the greatest experience in this field world
were invited as founding members of the forum. Great effort was addressed to
collect different series with comparable criteria. The criteria established by the
Society for Vascular Surgery (SVS) were reviewed and accepted, with some minor
changes. Common opinion was to consider both arterial and venous entrapment as
a common disease defined as vascular entrapment. The functional form of
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