An 82-year-old man with peripheral artery disease (PAD) was evaluated for a painful right foot. Over the past 3 weeks the patient began to have constant dull aching in his foot that improved when standing or walking. His pain was particularly intense at night, and he found that sleeping in a chair helped the disomfort. Three weeks prior to this presentation, small sores on the dorsal surface of the foot evolved and subsequently coalesced with dry gangrene in the small toe (Figure 92-1). The right foot was found to be tender, pulseless, cool, and ruborous with mild edema and elevation pallor.
An 82-year-old man with ischemic rest pain, extensive necrosis and dry gangrene of the 5th toe. Additionally, photograph A displays a bullous lesion along the lateral portion of the 3rd toe. Photograph B illustrates dependent rubor within the distal forefoot and distal cyanosis involving the 3rd toe.
Debridement of the wounds was subsequently performed (Figure 92-2) and aspirin and cilostazol were started. The ankle pressure on the right was 48 mm Hg with an ankle-brachial index (ABI) of 0.29. Infrainguinal arterial duplex ultrasound revealed diffusely monophasic waveforms with an occlusion of the distal superficial femoral artery. An angiogram further delineated an occlusion of the right external iliac artery that was treated with percutaneous atherectomy, angioplasty, and stent placement. The patient required a small-digit amputation that healed within 6 weeks after revascularization (Figure 92-3).
The patient from Figure 92-1 following revascularization and fifth digit amputation.
Lower extremity ulcers caused by ischemia from arterial disease are becoming more frequent in aging populations in Western countries.
In addition to age, risk factors include smoking, diabetes, hypertension, and dyslipidemia.
Chronic critical limb ischemia (CLI) is defined as ulcers and tissue loss or rest pain for more than 2 weeks without open lesions due to a lack of nutritive blood flow.
The 2007 TransAtlantic Inter-Society Consensus (TASC II) further defined CLI as an absolute ankle pressure of less than 50 mm Hg or a toe pressure of less than 30 mm Hg.
The incidence and prevalence of CLI has been difficult to calculate, but based on the assumption that 25% of patients with CLI will require amputation and that roughly 5% of claudicants will progress to CLI, one can estimate anywhere from 300 to 1000 affected patients per million per year.1
Arteriosclerosis occurs at a much younger age in diabetics with its hallmark ...
Log In to View More
If you don't have a subscription, please view our individual subscription options below to find out how you can gain access to this content.
Want remote access to your institution's subscription?
Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.
If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.
AccessCardiology Full Site: One-Year Subscription
Connect to the full suite of AccessCardiology content and resources including textbooks such as Hurst's the Heart and Cardiology Clinical Questions, a unique library of multimedia, including heart imaging, an integrated drug database, and more.
Pay Per View: Timed Access to all of AccessCardiology
24 Hour Subscription $34.95
48 Hour Subscription $54.95
Pop-up div Successfully Displayed
This div only appears when the trigger link is hovered over.
Otherwise it is hidden from view.