74 year old diabetic male admitted with non-healing lower extremity wounds and lower extremity pain at rest. History revealed a long standing history of intermittent limb claudication and progressively worsening wounds. The wounds began on the distal digits and progressed proximally. Inspection shows a gangrenous lower limb with inaudible Doppler signaling in the posterior tibialis or dorsalis pedis pulses. CT angiogram reveals severe superficial femoral artery and infrapopliteal disease. Given the extent of disease and limb non-viability, he underwent an above knee amputation.
Critical limb ischemia is defined lower extremity pain at rest for > 2 weeks associated with ankle systolic pressure of less than 50 mmHg, a toe systolic pressure of 30 mmHg or less, or a non-healing wound or gangrene of the foot or toe with comparable hemodynamics.
Management centers on aggressive cardiovascular risk factor reduction, pain control, local wound care, and timely revascularization. Options may include endovascular and surgical revascularization. Those who are not surgical candidates may require primary amputation.
Jaff, Michael and White, Christopher. Vascular Disease; Diagnostic and Therapeutic Approaches. Cardiotext. 2011