Prevent CLI to save limbs

Dr. Arvind Kohli
Critical Limb Ischemia (CLI) is a severe obstruction of            the arteries which markedly reduces blood flow to the extremities (hands, feet and legs) and has progressed to the point of severe pain and even skin ulcers or sores.
Critical limb ischemia results from a progressive thickening of an arteries lining (caused by a buildup of plaque). This buildup of plaque, also known as atherosclerosis, narrows or blocks blood flow, reducing circulation of blood to the legs, feet or hands..Ischemia is a severe condition and if unattended  can lead to tissue damage and loss of limbs.
The symptoms of ischemia depend upon how quickly the blood flow is interrupted and where it occurs. In the limbs, early symptoms of ischemia may include claudication (pain, burning, or cramping in the muscles with exercise that goes away with rest). This can progress over time to CLI, the reduction of blood flow to the affected extremity that results in severe pain or tissue loss. The pain is known as “rest pain” because it happens when resting or asleep. Usually, it wakes an individual up at night and can be relieved temporarily by hanging the leg over the bed or getting up to walk around. If the tissue of the limb has been affected, a non-healing sore or even gangrene may occur and the skin turns black; this requires immediate attention.
Warning Signs
Sudden onset of leg ischemia may cause severe pain, loss of pulses, coldness of the limb, paleness of the skin, and even leg weakness and loss of sensation and thickening of the toenails. It also requires immediate medical attention.
The risk factors are those for atherosclerosis (plaque buildup in the arteries): Smoking,is the main culprit for causing this ailment alongside advanced age, high cholesterol, high blood pressure, diabetes, a family history of cardiovascular disease, sedentary lifestyle, and obesity.
Clinical signs are most important in assessment of the disease. Non invasive vascular investigations like Ankle brachial index are very much helpful  Colour Doppler Duplex ultrasound imaging, Magnetic ResonanceAngiography, CTAngiogram, , or conventional arteriogram are the various investigations which can  be used to assess or diagnose disease .
Treatment of ischemia depends upon the location of the ischemia and its severity. However, for all forms of ischemia, controlling risk factors, especially smoking cessation, is essential! It may prevent progression of the ischemia and save  limb or  life. Treatment is focused upon getting more blood supply to the area of ischemia. So that claudication /rest pain or gangrene set in is prevented
Several medications may be prescribed to prevent further progression of the disease and to reduce the effect of contributing factors such as high blood pressure and cholesterol. Medications that fight infections, and pain medications may also be prescribed in certain cases.
Various medicines which are available include  rheology regulators like Cilostazole,statins antiplatelets and analgesics
If one experiences claudication in the legs or angina in the heart, a supervised exercise routine may be prescribed. Regular exercise may also result in other benefits such as weight loss, lower blood pressure, lower cholesterol, and better control of diabetes.
Surgery or Endovascular Procedures
In many cases, an endovascular procedure may be performed within the artery using clot-busting drugs to dissolve clots (thrombolysis), a balloon to widen the artery (angioplasty), and/or a wire reinforced stent  or device which remains inside the artery serving as a scaffolding to keep it open. Other treatments include laser atherectomy, where small bits of plaque are vaporized by the tip of a laser probe, and directional atherectomy, in which a catheter with a rotating cutting blade is used to physically remove plaque from the artery.
Open Surgery
* In some cases, a bypass of the affected artery may be performed. Either a segment of leg vein or an artificial tube graft made of PTFE  is attached surgically above and below the blockage to detour blood flow around the blocked area allowing the blood to reach the area of ischemia beyond the blockage. called as the Leg Bypass
* The last recourse would be amputation of a toe, part of the foot, or leg. Amputation occurs in about 25 percent of all CLI patients.
Concluding it is imperative that preventing PAD and CLI is the need . Avoiding Smoking is most important and so is Walking, more you walk good it is to prevent PAD,and controlling Hypertension,diabetes and hyperlipidemia is the key factor.
( The author is Vascular Surgeon SSH Jammu)