What is Leg Ischemia? Leg ischemia is the condition when the leg does not receive the necessary amount of oxygen (via the blood circulation) that is required for the activity underway.  How Do I Know if I Have Leg Ischemia? Ischemia of the lower extremities will manifest itself in
Claudication

The next “level” of ischemia is that of claudication. This is manifest by cramping pain that occurs with walking.  It most often affects the calf muscles and generally occurs at a rather fixed distance (usually measured in blocks.)  Depending on the severity of the ischemia—either by its level of lifestyle interference or by distance at which symptoms begin—it is referred to as Fontaine’s Class IIa or IIb. Rest Pain is the next Stage (III) in the Fontaine classification of leg ischemia.  This is typified by pain that occurs even in the absence of significant stress on the legs.  It often occurs in the evenings awakening the patient from sleep.  Quite often, hanging the leg from the side of the bed will improve the painful symptoms that are experienced.  The foot will often turn a light purple or deep red-violet color as it is held in a dependent condition—often referred to as “dependent rubor.”  This is a sign of significant leg ischemia and warrants aggressive intervention. The final stage of leg ischemia (Fontaine Level IV) is tissue loss—seen as a non-healing sore or

What Can Be Done About My Leg Ischemia?

The important step is recognizing the presence of limb ischemia!  Most cases of ischemia (Levels I and II) are most often treated without intervention other than lifestyle modification and risk factor adjustment.  However, once the symptoms have progressed to Level III (rest pain and beyond) aggressive and appropriate therapy is mandatory. 

Diagnosing limb ischemia is usually performed using noninvasive means in the Noninvasive Vascular Laboratory.  Simple tests can be performed to assess the degree of arterial insufficiency—tests that are noninvasive and cause no discomfort to perform.  The Vascular Surgeon can interpret them immediately and,
combined with physical examination and careful consideration of the medical history, make appropriate recommendations regarding the care that is right for that patient.  If indicated, an angiogram may be performed to assess if balloon angioplasty is appropriate or to plan a surgical procedure such as a bypass.  Irrespective of the procedure chosen, the goal is to improve blood flow to the limb and rid the patient of the ischemic symptoms.

When Should Intervention Be Performed?

We at The Cardiovascular Care Group have a strong belief—backed by decades of experience—that intervention (angioplasty or surgery) should be reserved as a “last resort” for the treatment of leg ischemia.  The vast majority of patients that we care for are best served by our conservative approach to limb ischemia.  Lifestyle adjustments (such as exercise programs and nutritional counseling) and risk factor modification (cessation of tobacco use, treatment of hypercholesterolemia) have proved quite successful to our patients over the years—without the need for intervention!  It is extremely rare that we will recommend intervention for those with claudication—most especially those whose claudication is not disabling. 

Having stated our conservative approach to claudication, it is imperative to understand that we feel that an aggressive approach to limb salvage is appropriate!  It was only three decades ago that it was believed that bypass surgery could not be performed with good results if the bypass had to extend below the level of the knee.  That belief has clearly (and appropriately) been discarded as microvascular techniques have been demonstrated, improved and perfected since the 1970s.  Bypass surgery to the vessels in the foot and ankle are routine for those with proper training in the field of Vascular Surgery.  Simply suggesting an amputation of the leg without evaluating the patient for a bypass is no longer conscionable except in the excessively old and infirmed patient who is nonambulatory to start!  Quite often once patients undergo a major amputation of the leg, the complications that ensue from their bedridden state lead to their demise.  We are quite proud of our results with limb salvage surgery and believe that it is an appropriate option for the great majority of patients.  We have cared for scores of patients over the years who have been informed that they had to have their leg amputated only to find that we were able to save it!

What is the Best Intervention—Balloon Angioplasty or Bypass Surgery?

The answer to this question depends on the individual patient.  Often one specific therapy is more appropriate than another; sometimes a combination of the two work best for a certain patient!  The most important advice that a patient can receive is to make sure that the person treating them is able to do everything—in that way, there is no inherent bias as to which procedure is best in that instance! 

What About the Results?

Results vary by interventionalist and by patient.  We have achieved outstanding results with angioplasty, stenting and bypass surgery—depending on the segment of the arterial tree and by the disease process.  Again, it is imperative that the physician making the decisions on the patient’s behalf has access to ALL treatment modalities before rendering an opinion!