Chapter 15: Critical Limb Ischemia
NITEN SINGH, MD; ZACHARY ARTHURS, MD
A 74-year-old patient is referred with recurrent cellulitis and pain in her left leg and inability to palpate pulses in the foot. She is an active smoker and has recently undergone percutaneous coronary intervention, with placement of 2 bare metal stents, for angina symptoms that have resolved. She was ambulatory before her pain limited her, and she cannot perform her cardiac rehabilitation due to her leg pain. She has chronic kidney disease but is not on dialysis. She states that her pain has been worsening over the last several months, to the point she has to sleep with her leg in the dependent position. Her medications include aspirin, clopidogrel, metoprolol, and simvastatin.
On physical examination, she appears frail and has a normal 2+ femoral pulse on the right and Doppler signal present at her left femoral artery. She does not have palpable pulses below this level. Doppler signals are present at the pedal level, with biphasic signals in her dorsalis pedis and posterior tibial artery on the right and only a monophasic signal present at the dorsalis pedis artery on the left. Her left leg has 1+ edema and is erythematous to the level of the knee when placed in the dependent position as opposed to the right leg, which has no edema or erythematous changes. The erythema in the left leg resolves when placed in the elevated position.
The resting ankle-brachial index (ABI) on the right was 0.7, with biphasic waveforms throughout the lower extremity. On the left, the resting ABI was 0.3, with monophasic waveforms throughout the lower extremity.