Intended for healthcare professionals

Practice Easily Missed?

Chronic limb threatening ischaemia

BMJ 2018; 360 doi: (Published 11 January 2018) Cite this as: BMJ 2018;360:j5460
  1. Kevin Barraclough, general practitioner1,
  2. Andrew Bradbury, professor of vascular surgery2
  1. 1Hoyland House, Painswick, UK
  2. 2University of Birmingham, Birmingham, UK
  1. Correspondence to K Barraclough k.barraclough{at}

What you need to know

  • Chronic limb threatening ischaemia (CLTI) is a more difficult diagnosis than acute limb ischaemia for the non-specialist because the clinical features can be more subtle and gradual in onset

  • It can be easy to mistake CLTI for other conditions, such as cellulitis, gout, or plantar fasciitis

  • The affected foot might appear pink or red as a result of reactive hyperaemia when the patient is sitting with the leg down. It is often necessary to elevate the foot on the examination couch to elicit the ischaemic pallor.

A 72 year old ex-smoker with diabetes presents to his general practitioner with a 4 week history of increasing pain in his right foot, worse at night. He finds hanging the leg down provides some relief and he now sleeps in a chair. His leg is increasingly swollen. A cut on his foot has failed to heal and is now red and discharging. On examination, there are no pulses below the femoral artery. The right foot is cold and pale on elevation, and hyperaemic upon dependency. The GP diagnoses chronic limb threatening ischaemia (CLTI) and the patient is seen in the vascular clinic on the same day and admitted. He undergoes imaging and vein bypass surgery. He is discharged a week later free of pain with a healing foot wound.

Peripheral arterial disease affects 10%-20% of patients over 60 and presents in several ways123 (table 1). A quarter of patients have symptoms, typically intermittent claudication, of whom 1%-2% progress to CLTI each year.2 However, many patients with CLTI do not have a history of intermittent claudication and present de novo with ischaemic rest (night) pain and/or a non-healing foot wound. This is either because they cannot, or choose not to, walk far enough to bring on …

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