Critical Limb Ischemia (CLI) is a condition where blood flow to the legs and feet is blocked.
When blood flow is blocked to an arm or leg, that limb is in danger of not surviving.
Left untreated, critical limb ischemia can lead to amputations.
Learn the symptoms and available treatments from Dr. Kanwar Singha, a UVA Heart & Vascular Center specialist in vascular disease.
Selected Podcast
Treatment Options for Critical Limb Ischemia
Featured Speaker:
Kanwar Singh, MD
Dr. Kanwar Singh is a board-certified physician in interventional cardiology, cardiovascular disease and internal medicine whose specialties include critical limb ischemia and peripheral arterial disease. Transcription:
Treatment Options for Critical Limb Ischemia
Melanie Cole (Host): If left untreated, critical limb ischemia can lead to amputations. My guest today is Dr. Kanwar Singh. He’s a board certified physician in Interventional Cardiology, Cardiovascular Disease, and Internal Medicine whose specialties include critical limb ischemia and peripheral artery disease at UVA Heart and Vascular Center. Welcome to the show, Dr. Singh. Tell us a little bit about what critical limb ischemia is.
Dr. Kanwar Singh (Guest): Good morning, and thank you so much for the opportunity to share some thoughts about critical limb ischemia. Critical limb ischemia is defined as breath pain, tissue alteration, or gangrene as the function of abnormal circulation to the leg.
Melanie: Wow! What would cause this? Why would somebody even have these kinds of problems? Is it associated with certain diseases, diabetes, peripheral artery disease?
Dr. Singh: Absolutely. I tell patients all the time that artery disease is artery disease, meaning people who have coronary artery disease in their heart’s arteries or carotid artery disease in their neck’s arteries are the same types of patients who develop the same sort of blockages in their leg artery. If a person has eczema, a rash on their elbows or a rash on their knees and a rash on their neck, we don’t describe them as having neck eczema, knee eczema. We describe them as having eczema. It’s a total body condition. It’s a rash. And an artery disease is much the same way. The same things that cause the blockages in other important parts of the body contribute to the development of blockages in the legs. Namely, tobacco smoke is the number one risk factor. People who are smokers are at a substantially increased risk of developing clogs in their arteries that threaten the very existence of their legs. They lose their toes, they lose their ankles, they lose their knees, or even higher up. Diabetes is another major contributor. It tends to affect the smaller artery, typically of the lower legs, meaning the calf and below down into the feet, and it’s a major cause of amputation in this population. And then certainly, the other traditional risk factors, such as high cholesterol or high blood pressure, can also be contributors. But really, it’s the smokers and the diabetic folks who suffer the most at the hands of this condition.
Melanie: The risk factors—smoking, diabetes—is this a hereditary thing in peripheral vascular disease, just arterial lower limb disease? Is this something that’s hereditary?
Dr. Singh: It certainly can be, and we certainly know families where artery disease runs rampant among parents, uncles, aunts, relatives, et cetera. There aren’t so much genetic predictors that we’re looking at in terms of doing screening or blood testing or things like that to identify people at particular risk. It’s not as if it’s an inherited condition that is so classically or elegantly associated with a gene deletion on such and such a chromosome. It’s more of an overall risk factor that can run in families. Frankly, I think a lot of families who share risk factors genetically also share risk factors socially, namely self-injurious behaviors, like smoking to excess or even being around excess amounts of smoking, even if you’re not the primary tobacco user yourself.
Melanie: And even being overweight can run in families. Obesity can contribute to this. What about sedentary lifestyle? And what role does exercise play? I’m an exercise physiologist, Dr. Singh, so to me, keeping that blood flow in the legs, keeping your body moving gets that blood and keeps it from pooling. Does that contribute to this?
Dr. Singh: That’s such an excellent point. I’m so glad you brought it up. Exercise, exercise, exercise in the form of low level walking. It needn’t be necessarily going out for a trail-busting run. It need not be necessarily getting one’s heart rate up over 150 beats per minute. In fact, that may not be necessarily the most helpful thing to do. But plain, good old-fashioned walking, walking, walking is a tremendously valuable tool in the armamentarium of patients to help prevent developing peripheral artery disease, and more importantly the symptoms that peripheral artery disease can lead to. So even if one has blockages in the legs, the more active you remain, the less likely you are to develop a sore or an ulcer that thereby leads to an infection and that thereby increases your risk of developing an amputation.
Melanie: Women especially get concerned when they start to feel pains in their calves if they’re walking or if they’re exercising and they’re busy around the house. They always think right away blood clots or constrictions in their legs. Are there certain symptoms, red flags? Do they have to look for certain things to worry about lower limb clots or blockages?
Dr. Singh: That’s another great question. It’s important to distinguish what I call the northbound and the southbound traffic of blood flow. The southbound traffic would be blood that’s flowing from your heart down toward the leg, muscles, and the skin of your lower extremity. And that’s of course being pumped by your heart through our artery. The blood then gets to our lower legs, and it then pools in the venous circulation, and then it’s transported back up the leg towards the heart in veins that are responsible for the venous return of circulation. And believe it or not, the conditions that affect the veins and that affect the arteries are very, very different and completely unrelated. There are lots of young folks under the age of 35 who might have venous problems, either varicose veins or incompetent valves of their veins that result in leg swelling or spiders or varicose veins that folks can see and might identify. Those sorts of things, those vein problems can actually cause symptoms in the calf muscles or thigh muscles or a sense of leg fullness simply because there’s this sort of soggy leg with lots of blood that’s not getting great blood return out of it back up towards the heart. That’s very different from the southbound traffic problem, where there’s a constriction of blood flow because of a clog or some sort of blockage in the arterial blood flow that’s going down the leg. The symptoms to be aware of, classically speaking, are things like leg heaviness, leg fullness, cramping, pain, or occasionally tingling that is most present with exertion. That is the typical hallmark pattern symptom complex of arterial insufficiency, arterial blockage. It’s pain that develops in the calves or in the thighs or occasionally, in the buttocks muscles—because they need blood flow too—on exertion that is relieved by rest.
Melanie: Then what do you do for them? Does it always require surgery? Is it something with blood thinners, something that can be taken care of with medication? What’s the first line of defense?
Dr. Singh: I tend to think of this as two separate buckets of treatment. The first bucket of treatment is to deal with the symptoms that the patient is experiencing. Those symptoms can be thought broadly into categories also. The person who has leg symptoms when they walk and is relieved by rest, that is more commonly a very stable situation. In other words, it’s unlikely to rapidly progress and deteriorate. Those folks will say, “Gosh, doc. I walked a city block or I walked out of my driveway to my mailbox and back, and my calf muscles are burning. But by the time I get back inside, I rest, I feel fine and I’m okay.” Those patients who have symptomatic, what we call claudication or muscle pain on exertion, they will most often respond to a prescribed exercise regimen and don’t at all necessarily require treatment, either with balloons, and catheters and stent, the kind of work that I do, or with surgery, bypass surgery or clog opening surgery called endarterectomy or bypass that my surgical teammates and colleagues do at UVA. That’s sort of one category of symptoms, the stable claudicate, “my legs hurt when I walk.” The second category of symptoms are the critical limb patients. Those are the ones who have pain at rest or tissue ulceration or gangrene at rest. In other words, there’s just not enough blood flow getting down the leg to keep the very skin alive on the outside of their leg, and that’s an emergency. That’s something that needs attention in the next one to two days to be seen by someone and then a plan made for how to get that circulation back and relieve the symptom of pain or the risk of amputation. Overall, that’s sort of one bucket. It does not at all necessarily require surgery, although many times what is recommended are minimally invasive procedure with balloons and catheters and stents to relieve the blockages, restore blood flow, and optimize the benefits of healing and getting that skin back to be intact. That’s the first bucket, treating the symptomatic leg. The second bucket is recognizing that these patients who have leg artery blockages, the most likely reason that they’re going to end up getting sick enough to be at risk of death is something like heart attack or stroke. And so, in addition to treating the leg symptom, we also have to make sure that these patients are being monitored and treated for the presence of coronary artery disease or carotid artery disease that that would take their life in the form of heart attack or stroke. Those patients need to be at appropriate blood pressure control, medication, diabetes control medication, cholesterol control medication, and have to be living an overall healthy lifestyle to the best of their ability to reduce their overall cardiovascular morbidity and mortality.
Melanie: Wow, very well put. Such great information. In just the last minute, give your best advice to people suffering from this claudication, what you really want them to know, and why they should come to the UVA Heart and Vascular Center for their care.
Dr. Singh: Well, I’m very fortunate to work at one of the absolutely best centers in the country, if not the world, for the treatment of patients with lower leg artery disease. And I say that because we have a unique group of surgeons, intervention radiologists, as well as cardiologists, including myself, who take care of this condition holistically and don’t just think of this as a plumbing problem that needs relief. We think of the whole patient who need to have their risk factors modified, their symptoms treated, and their overall health optimized. The patient with claudication needs to recognize that they have this problem to have to talk carefully with their providers about it and make sure that their overall risk profile is minimized. If they’re symptomatic enough that it’s lifestyle limiting—they’re a postal carrier and they can’t get around or do their job, or they’re a line dancer and they can’t get out and dance with their partner—if it’s affecting their lifestyle, then they warrant an intervention, a balloon treatment or a stent treatment or surgery—rarely, but if indicated. For those patients, the primary to think about is getting out of trouble and preventing the downstream complication that leads to limb loss.
Melanie: Thank you so much, Dr. Singh. You’re listening to UVA Health Systems Radio. For more information, you can go to uvahealth.com. That’s uvahealth.com. This is Melanie Cole. Thanks so much for listening.
Treatment Options for Critical Limb Ischemia
Melanie Cole (Host): If left untreated, critical limb ischemia can lead to amputations. My guest today is Dr. Kanwar Singh. He’s a board certified physician in Interventional Cardiology, Cardiovascular Disease, and Internal Medicine whose specialties include critical limb ischemia and peripheral artery disease at UVA Heart and Vascular Center. Welcome to the show, Dr. Singh. Tell us a little bit about what critical limb ischemia is.
Dr. Kanwar Singh (Guest): Good morning, and thank you so much for the opportunity to share some thoughts about critical limb ischemia. Critical limb ischemia is defined as breath pain, tissue alteration, or gangrene as the function of abnormal circulation to the leg.
Melanie: Wow! What would cause this? Why would somebody even have these kinds of problems? Is it associated with certain diseases, diabetes, peripheral artery disease?
Dr. Singh: Absolutely. I tell patients all the time that artery disease is artery disease, meaning people who have coronary artery disease in their heart’s arteries or carotid artery disease in their neck’s arteries are the same types of patients who develop the same sort of blockages in their leg artery. If a person has eczema, a rash on their elbows or a rash on their knees and a rash on their neck, we don’t describe them as having neck eczema, knee eczema. We describe them as having eczema. It’s a total body condition. It’s a rash. And an artery disease is much the same way. The same things that cause the blockages in other important parts of the body contribute to the development of blockages in the legs. Namely, tobacco smoke is the number one risk factor. People who are smokers are at a substantially increased risk of developing clogs in their arteries that threaten the very existence of their legs. They lose their toes, they lose their ankles, they lose their knees, or even higher up. Diabetes is another major contributor. It tends to affect the smaller artery, typically of the lower legs, meaning the calf and below down into the feet, and it’s a major cause of amputation in this population. And then certainly, the other traditional risk factors, such as high cholesterol or high blood pressure, can also be contributors. But really, it’s the smokers and the diabetic folks who suffer the most at the hands of this condition.
Melanie: The risk factors—smoking, diabetes—is this a hereditary thing in peripheral vascular disease, just arterial lower limb disease? Is this something that’s hereditary?
Dr. Singh: It certainly can be, and we certainly know families where artery disease runs rampant among parents, uncles, aunts, relatives, et cetera. There aren’t so much genetic predictors that we’re looking at in terms of doing screening or blood testing or things like that to identify people at particular risk. It’s not as if it’s an inherited condition that is so classically or elegantly associated with a gene deletion on such and such a chromosome. It’s more of an overall risk factor that can run in families. Frankly, I think a lot of families who share risk factors genetically also share risk factors socially, namely self-injurious behaviors, like smoking to excess or even being around excess amounts of smoking, even if you’re not the primary tobacco user yourself.
Melanie: And even being overweight can run in families. Obesity can contribute to this. What about sedentary lifestyle? And what role does exercise play? I’m an exercise physiologist, Dr. Singh, so to me, keeping that blood flow in the legs, keeping your body moving gets that blood and keeps it from pooling. Does that contribute to this?
Dr. Singh: That’s such an excellent point. I’m so glad you brought it up. Exercise, exercise, exercise in the form of low level walking. It needn’t be necessarily going out for a trail-busting run. It need not be necessarily getting one’s heart rate up over 150 beats per minute. In fact, that may not be necessarily the most helpful thing to do. But plain, good old-fashioned walking, walking, walking is a tremendously valuable tool in the armamentarium of patients to help prevent developing peripheral artery disease, and more importantly the symptoms that peripheral artery disease can lead to. So even if one has blockages in the legs, the more active you remain, the less likely you are to develop a sore or an ulcer that thereby leads to an infection and that thereby increases your risk of developing an amputation.
Melanie: Women especially get concerned when they start to feel pains in their calves if they’re walking or if they’re exercising and they’re busy around the house. They always think right away blood clots or constrictions in their legs. Are there certain symptoms, red flags? Do they have to look for certain things to worry about lower limb clots or blockages?
Dr. Singh: That’s another great question. It’s important to distinguish what I call the northbound and the southbound traffic of blood flow. The southbound traffic would be blood that’s flowing from your heart down toward the leg, muscles, and the skin of your lower extremity. And that’s of course being pumped by your heart through our artery. The blood then gets to our lower legs, and it then pools in the venous circulation, and then it’s transported back up the leg towards the heart in veins that are responsible for the venous return of circulation. And believe it or not, the conditions that affect the veins and that affect the arteries are very, very different and completely unrelated. There are lots of young folks under the age of 35 who might have venous problems, either varicose veins or incompetent valves of their veins that result in leg swelling or spiders or varicose veins that folks can see and might identify. Those sorts of things, those vein problems can actually cause symptoms in the calf muscles or thigh muscles or a sense of leg fullness simply because there’s this sort of soggy leg with lots of blood that’s not getting great blood return out of it back up towards the heart. That’s very different from the southbound traffic problem, where there’s a constriction of blood flow because of a clog or some sort of blockage in the arterial blood flow that’s going down the leg. The symptoms to be aware of, classically speaking, are things like leg heaviness, leg fullness, cramping, pain, or occasionally tingling that is most present with exertion. That is the typical hallmark pattern symptom complex of arterial insufficiency, arterial blockage. It’s pain that develops in the calves or in the thighs or occasionally, in the buttocks muscles—because they need blood flow too—on exertion that is relieved by rest.
Melanie: Then what do you do for them? Does it always require surgery? Is it something with blood thinners, something that can be taken care of with medication? What’s the first line of defense?
Dr. Singh: I tend to think of this as two separate buckets of treatment. The first bucket of treatment is to deal with the symptoms that the patient is experiencing. Those symptoms can be thought broadly into categories also. The person who has leg symptoms when they walk and is relieved by rest, that is more commonly a very stable situation. In other words, it’s unlikely to rapidly progress and deteriorate. Those folks will say, “Gosh, doc. I walked a city block or I walked out of my driveway to my mailbox and back, and my calf muscles are burning. But by the time I get back inside, I rest, I feel fine and I’m okay.” Those patients who have symptomatic, what we call claudication or muscle pain on exertion, they will most often respond to a prescribed exercise regimen and don’t at all necessarily require treatment, either with balloons, and catheters and stent, the kind of work that I do, or with surgery, bypass surgery or clog opening surgery called endarterectomy or bypass that my surgical teammates and colleagues do at UVA. That’s sort of one category of symptoms, the stable claudicate, “my legs hurt when I walk.” The second category of symptoms are the critical limb patients. Those are the ones who have pain at rest or tissue ulceration or gangrene at rest. In other words, there’s just not enough blood flow getting down the leg to keep the very skin alive on the outside of their leg, and that’s an emergency. That’s something that needs attention in the next one to two days to be seen by someone and then a plan made for how to get that circulation back and relieve the symptom of pain or the risk of amputation. Overall, that’s sort of one bucket. It does not at all necessarily require surgery, although many times what is recommended are minimally invasive procedure with balloons and catheters and stents to relieve the blockages, restore blood flow, and optimize the benefits of healing and getting that skin back to be intact. That’s the first bucket, treating the symptomatic leg. The second bucket is recognizing that these patients who have leg artery blockages, the most likely reason that they’re going to end up getting sick enough to be at risk of death is something like heart attack or stroke. And so, in addition to treating the leg symptom, we also have to make sure that these patients are being monitored and treated for the presence of coronary artery disease or carotid artery disease that that would take their life in the form of heart attack or stroke. Those patients need to be at appropriate blood pressure control, medication, diabetes control medication, cholesterol control medication, and have to be living an overall healthy lifestyle to the best of their ability to reduce their overall cardiovascular morbidity and mortality.
Melanie: Wow, very well put. Such great information. In just the last minute, give your best advice to people suffering from this claudication, what you really want them to know, and why they should come to the UVA Heart and Vascular Center for their care.
Dr. Singh: Well, I’m very fortunate to work at one of the absolutely best centers in the country, if not the world, for the treatment of patients with lower leg artery disease. And I say that because we have a unique group of surgeons, intervention radiologists, as well as cardiologists, including myself, who take care of this condition holistically and don’t just think of this as a plumbing problem that needs relief. We think of the whole patient who need to have their risk factors modified, their symptoms treated, and their overall health optimized. The patient with claudication needs to recognize that they have this problem to have to talk carefully with their providers about it and make sure that their overall risk profile is minimized. If they’re symptomatic enough that it’s lifestyle limiting—they’re a postal carrier and they can’t get around or do their job, or they’re a line dancer and they can’t get out and dance with their partner—if it’s affecting their lifestyle, then they warrant an intervention, a balloon treatment or a stent treatment or surgery—rarely, but if indicated. For those patients, the primary to think about is getting out of trouble and preventing the downstream complication that leads to limb loss.
Melanie: Thank you so much, Dr. Singh. You’re listening to UVA Health Systems Radio. For more information, you can go to uvahealth.com. That’s uvahealth.com. This is Melanie Cole. Thanks so much for listening.