1. Approach to CLI – Consider Arterial & Venous Insufficiency
Khusrow Niazi, MD, FACC, FSCAI
Director, Peripheral Vascular Intervention
Emory University
Atlanta, USA

2. Khusrow Niazi, MD, FACC, FSCAI
Disclosure:
Research Grants:
Medtronic
Bard Peripheral
Spectranetics
Speaker/Consultant:
Examples of relationships are: Advisory Board/Board Member, Consultant, Honoraria, Research Support, Speaker’s Bureau, Stockholder
Please list full company name

3. Peripheral Vascular Disease – elephant in your waiting room

4. PVD

5. ? Dermatologic disease Arterial insufficiency Venous insufficiency
Malignant lesion
I D K
5. I don’t know

7. “….cognitive impairment…..”

8. RN – 67yoM Impression: 1. Nonhealing wound on his left leg above the
medial malleolus for past couple of weeks.
2. Right below-knee amputation after 2 attempts at
percutaneous revascularization on the right leg for a wound on his right foot, a yr back in North Carolina.
3. Diabetes mellitus for past 15 years.
4. Hypertension.
5. Past history of pericarditis.
6. Systolic murmur suggesting aortic stenosis.

10. Recommendations:
1.The patient had an ABI performed a week before by vascular surgery on his left lower extremity, and Proceed with an MRA to define the extent of arterial disease in his left lower extremity.
2. Venous Doppler ultrasound.
3. Echocardiogram to assess his cardiac murmur.

13. Revascularization of left trifurcation

17. 4 weeks after presentation

18. Venous Doppler
Severe reflux in the left GSV >3sec
GSV 6.3mm

19. 4 weeks after presentation
Ablation of left GSV

20. 8 weeks

21. 8 weeks
ABI
1.1 and 0.96

22. 11 weeks

23. ?
STOP

24. Amputations in the U.S.
Approximately 185,000 amputations occur in the U.S. each year1 [all cause amputations]
82% of all amputations in the U.S. are due to vascular disease2
97% are lower extremity amputations2
The risk of major amputation is increased significantly when total occlusion is present in the Popliteal and Infrapopliteal arteries3
1. .org/fact_sheets/limbloss_us.html
2. Hakimi, Kevin. “Pre-Operative Rehabilitation Evaluation of the Dysvascular Patient Prior to Amputation.” Phys Med Rhabil Clin N Am 20, 2009:
3. Faglia et al. “Angiographic Evaluation of Peripheral Arterial Occlusive Disease and its Role as a Prognotstic Determinant for Major Amputation in Diabetic Subjects with Foot Ulcers” Diabetes Care. 1998; vol 21, no 4:

26. After arterial
recannalization
After venous
ablation

27. Annual Incidence and Prevalence of Venous Insufficiency
Venous reflux disease is 2x more prevalent than coronary heart disease (CHD) and 5x more prevalent than peripheral arterial disease (PAD)1

28. When do I suspect CVI

29. Clinical Suspicion of CVI
Heredity
Age
Female sex
Obesity
Pregnancy
Prolonged standing
Greater height
Obesity
Pregnancy
Prolonged standing
Greater height

30. Clinical Suspicion of CVI
Leg Pain or Aching or Heaviness
Leg Cramps or Tingling
Leg Swelling or feeling of swelling
Itching
Restless Legs
Varicose veins
Blood Clots
Bleeding
Ulcers

31. ?
How do you diagnose?

32. Transverse view of GSV

35. Take home message…..

36. Location of Ulcer
J Vasc Surg 2007;45:S5-S67

37. History Leg pain/ulcer Physical exam Arterial insufficiency
Venous insufficiency
Other causes
ABI
Venous Doppler