Chronic lower limb ischaemia

The leg is affected eight times more commonly than the arm because:

• (he arterial supply lo the leg is less well developed

• the lower limb is more frequently affected by atherosclerosis.

In many patients the pedal pulses may he absent or diminished. However, the presence of pedal pulses at rest does not exclude a significant lower limb PAD. If the history is convincing ask the patient to walk until the onset of pain. If the symptoms are vascular in origin the pulses will disappear. Additional ischaemic changes may be present: for example, there may be absence of body hair on toes and dorsum of the feet. Other clinical features of arterial claudication are illustrated in Table .1.32.

Changes are more severe once (here is critical limb ischaemia. Such patients will have an ankle blood pressure of <50mmHg and a positive Buerger's test. This is indicated by the presence of rubor of the forefoot (sunset foot) due to reactive hyperaemia within 2-3 minutes of the legs becoming dependent. Severe chronic ischaemia of the limb is associated with the onset of extreme pallor of the sole of (he foot and emptying, so-called 'guttering', of the dorsal foot veins with the leg elevated.

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Essentials of Human Physiology

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