Intended for healthcare professionals

Clinical Review ABC of arterial and venous disease

Chronic lower limb ischaemia

BMJ 2000; 320 doi: (Published 25 March 2000) Cite this as: BMJ 2000;320:854
  1. Jonathan D Beard

    Peripheral vascular disease commonly affects the arteries supplying the leg and is mostly caused by atherosclerosis. Restriction of blood flow, due to arterial stenosis or occlusion, often leads patients to complain of muscle pain on walking (intermittent claudication). Any further reduction in blood flow causes ischaemic pain at rest, which affects the foot. Ulceration and gangrene may then supervene and can result in loss of the limb if not treated. The Fontaine score is useful when classifying the severity of ischaemia.

    Fontaine classification of chronic leg ischaemia

    Stage I Asymptomatic

    Stage II Intermittent claudication

    Stage III Ischaemic rest pain

    Stage IV Ulceration or gangrene, or both

    Angiogram showing bilateral occlusions of superficial femoral arteries in thighs. Collaterals arising from the profunda femoris artery can functionally bypass this occlusion

    Although many patients with claudication remain stable, about 150–200 per million of the population progress to critical limb ischaemia (Fontaine III or IV) each year. Many patients with critical limb ischaemia can undergo revascularisation, which has a reasonable chance of saving the limb. A recent audit by the Vascular Surgical Society found a success rate of over 70% for these patients. However, many patients still require major amputation. Rehabilitation of elderly patients after amputation can prove difficult, with high community costs. Critical limb ischaemia has been estimated to cost over £200m a year in the United Kingdom.

    Intermittent claudication

    History and examination

    A history of muscular, cramp-like pain on walking that is rapidly relieved by resting, together with absent pulses, strongly supports the diagnosis of intermittent claudication. Disease of the superficial femoral artery in the thigh results in absent popliteal and foot pulses and often causes calf claudication. Disease of the aorta or iliac artery results in a weak or absent femoral pulse, often associated with a femoral bruit. Disease at this level may cause calf, thigh, or buttock claudication.

    Method of palpating …

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