Leg attack

Dr Arvind Kohli
The term leg attack is similar to a heart attack. The blood supply to the leg gets blocked, resulting in pain while walking. The difference is that a patient can die of heart attack, but loses a leg during a leg attack.
People with such condition, medically as gangrene, have constant pain while walking. They have to take a break before being able to walk again. Severe continuous pain in the leg with pre-gangrenous color change is called rest pain. Such patients usually sleep on a chair as it is difficult to lie down.
Gangrene occurs when the blood supply to the leg is severely affected. The toes become black and may need amputation. The blood supply needs to be restored before cutting the toes or else the cut area also becomes gangrenous, eventually requiring amputation.
How does Leg Attack Happen ?
In most patients, Leg attack or critical limb is- chemia (CLI) is related to “hardening of the arteries’’, also called “atherosclerosis. “When there is no longer enough blood getting to tissues to keep them alive, the tissues begin to die, and that is when patients develop ulcers and gangrene. Patients and diabetes may have “neuropathy’’ which is a type of nerve damage that prevents them from feeling injury to the feet. This may make them more likely to develop sores on the feet since they can’t tell when they have injured themselves. Also, diabetics have a harder time fighting off infection so they are more likely to get a deep wound infection or a bone infection (osteomyelitis).
Clinical Signs of Leg Attack:  Leg attack can be an emergency. It is sort of like having a “heart attack in your feet’’. Patients may need to come into the hosptal right away to get revascularized. Physicians are taught to remember the 5- “P’s’’ :Absence of Pulse, presence of resting Pain, Pallor  (whitish color to the skin), Paresthesia (lack of sensation) and Paralysis (not being able to move the foot).
Non Healing Ulcers : (wounds) usually appear in the tips of the toes, or over bony areas. They can be on the leg. These sores are associated with severe pain (except in diabetic patients with neuropathy). The ulcers are generally dry (they do not drain much fluid) and the bottom of the ulcer is often pale, gray or covered with black tissue or dead tissue.
* Dry Gangrene : The presence of dead tissue is one of the last stages of CLI. It is usually very painful. It can smell bad.
* Absence of Palpable Pulses : A doctor should examine the pulses of the feet to determine if it is possible to feel the pulses in the top of the foot and the back of the ankle. If these pulses cannot be felt, it may be possible to hear them with an instrument called a “Doppler”. The physician may also measure the blood pressure in the arm and in the foot and compare  these measurements. The ankle brachial index (ABI) is the ratio between the ankle systolic blood pressure and the brachial (arm) systolic blood pressure. In patients with CLI the ABI is almost universally below 0.5. However, in diabetics this test may not be reliable because of hardening of the arteries.
Vascular Screening with Transcutaneous Oxymetry :
Transcutaneous oxymetry (TCOM) measures the amount of oxygen in the skin using a special heated sensor. TCOM can be used to determine whether patients are likely to  heal a wound, whether they might need an angiogram, and whether revascularization has worked. It can also be used to predict the outcome of patients requiring amputation.
*  Magnetic resonance arteriography  Angiography
Magnetic resonance arteriography/CT angiography have recently become one of the preferred methods of evaluation of CLI.  MRA/CTA does not require that dye be injected directly into the arteries. A small amount of dye can be placed into an arm vein (dye which is not likely to be dangerous to kidney function( Digital Subtraction Angiography (DSA) is concluding as far as decision making is concerned.
Surgical Revascularization
There are different surgical techniques for revascularization. Whether surgery is right for you depends on  where the blockage is. However surgical intervention can limit the progression of gangrene. The gangrenous part has to be sacrificed.
Endovascular Therapy
In the past two decades, endovascular therapy has revolutionized the treatment of patients with vascular disease. In patients with a lot of other medical problems  for whom surgery is risky, endovascular therapy is often the first choice. It has in many ways revolutionized the management of leg attack. Only issue concerning the endovascular therapy is affordability.
Amputation
For patients who are not candidates for revascularization amputation is an important treatment option. The level of amputation and the potential for effective rehabilitation are the two main factors to take into account. Sometimes we do revascularization in order to ensure that patients lose as little of the foot as possible so that they can continue to be able to walk. In other words, sometimes amputating toes can get rid of pain and allow patients to get back to walking again once the amputation site has healed.
(The author is Vascular Surgeon SSH Jammu)

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