The incidence of Critical Limb Ischemia (CLI) or ‘Leg Attack’ is very high in India but unlike brain attack and heart attack, there are very few people who have even heard about something called a leg attack. It can be disastrous and even fatal; even more dangerous than a brain attack.
The problem occurs largely among the diabetic population in India. 20 per cent of all diabetic people suffer from critical limb ischemia every year. Many patients invariably lose their limbs (amputation) and sometimes if the infection spreads further, also their lives. A study published in the New England Journal of Medicine quotes that 43 per cent of diabetic patients undergoing foot amputation are likelier to lose their life within 5 years – underlining the seriousness of the untreated diabetic foot. Their feet are prone to arterial clogs and blocks, and other infections. Hence all diabetics are advised to treat their feet with greater care than even their face.
Diabetes, high BP, high cholesterol and smoking may pose as risk factors for peripheral artery disease. Often people with a mild form of the disease do not show any symptoms. But diabetics are advised to get their foot checkup, like Ultrasound Doppler studies. These must be done once in a year so that detection can be done as early as possible.
THE RISK FACTORS FOR CRITICAL LIMB ISCHEMIA
CLI is a very severe condition of peripheral artery disease (PAD) and needs comprehensive treatment by a vascular surgeon or vascular specialist. It is a serious condition that requires immediate treatment to re-establish blood flow to the affected area or areas. (Most patients with CLI have multiple arterial blockages.) Treatment for CLI can be quite complex and individualised, but the overall goal should always be to reduce the pain and improve blood flow to save the leg.
The number one priority is to preserve the limb – prevent an amputation.
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, high cholesterol and diabetes, and most certainly to reduce the pain. Medications that prevent clotting or fighting infections may also be prescribed, but blockages once developed cannot be opened with medicines.
These treatments are the least invasive and involve inserting a catheter into the artery from the leg to allow access to the affected portion of the artery. Angioplasty may be done to open blockages by using small balloons introduced on a catheter into an artery. The balloon is inflated and, as it inflates, it stretches and opens the artery for improved blood flow. A metallic device called a ‘stent’ can then be inserted to maintain the expanded artery, thereby improving blood flow to the limb.
Another treatment is atherectomy, in which a catheter with a rotating cutting blade is used to physically remove plaque from the artery, just like shaving with a blade.
If the arterial blockages are not favourable for endovascular therapy, surgery is often recommended. This involves removing or bypassing the arterial disease using either a vein from the patient or a synthetic graft. In a few cases, the surgeon may open the artery and scrape out the blockage keeping the original artery functional.
Severe pain in muscles or numbness in the legs and feet while a person is walking
A noticeable decrease in the temperature of your lower leg or foot compared to the rest of your body
Toe or foot sores, infections or ulcers that will not heal or heal very slowly (longer than 10 days)
Gangrene (dead area)
Shiny, smooth, dry skin in the legs or feet
Thickening of the toenails
Absent or diminished pulse in the legs or feet
This is the last resort. This could mean amputation of a toe, part of the foot, or the entire leg. Amputation occurs in about 25 per cent of all CLI patients – a devastating complication of misdiagnosis, delayed diagnosis or incompletely treated diabetic foot.
Since treatment depends on the severity of the disease and many individual parameters, it is essential that someone with ulcers or pain in the legs or feet – when walking or at rest – sees a vascular specialist as soon as possible. The sooner the diagnosis can be made, the earlier the treatment can start with less serious consequences. Do not undergo amputation/surgical procedures on the foot without confirming the blood supply to the area.
Dr. Rajiv Parakh, Chairman , Vascular Department , Medanta - The Medicity