Management of Critical Limb Ischemia

Abstract

Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as non-healing ulcers or gangrene, related to peripheral artery disease. CLI has a high short-term risk of limb loss and cardiovascular events. Non-invasive or invasive angiography help determine the feasibility and approach to arterial revascularization. An “endovascular-first” approach is often advocated based on a lower procedural risk, however, specific patterns of disease may be best treated by open surgical revascularization. Balloon angioplasty and stenting form the backbone of endovascular techniques, with drug-eluting stents and drug-coated balloons offering low rates of repeat revascularization. Combined antegrade and retrograde approaches can increase success in long total occlusions. Below the knee, angiosome-directed angioplasty may lead to greater wound healing, but failing this, any straight line flow into the foot is pursued. Hybrid surgical techniques such as iliac stenting and common femoral endarterectomy are commonly used to reduce operative risk. Lower extremity bypass grafting is most successful with a good quality, long, single-segment autogenous vein of at least 3.5mm diameter. Minor amputations are often required for tissue loss as part of the treatment strategy. Major amputations (at or above the ankle) limit functional independence and their prevention is a key goal of CLI therapy. Medical therapy after revascularization targets risk factors for atherosclerosis and assesses wound healing and new or recurrent flow limiting disease. The ongoing NIH sponsored BEST-CLI study is a randomized trial of the contemporary endovascular versus open surgical techniques in patients with CLI.

Peripheral arterial disease: Scoping review of patient‐centred outcomes

“…More rigorous evaluator‐blind RCTs on patients with PAD are needed to confirm the effects on patient‐centred outcomes of systemic prostanoids, growth factors, hyperbaric oxygen, anaesthetic topical cream, ibuprofen foam dressings, or extracorporeal shock wave therapy. By the time, patients require surgical bypass or invasive revascularisation interventions, amputation, disability, and mortality are expected outcomes . Future rigorously controlled, blind evaluated studies stratifying outcome analyses by patient PAD severity are needed to clarify longer term effects on long‐term patient‐centred outcomes including costs, amputation risk, and mortality …”

“…By the time, patients require surgical bypass or invasive revascularisation interventions, amputation, disability, and mortality are expected outcomes. 126 Future rigorously controlled, blind evaluated studies stratifying outcome analyses by patient PAD severity are needed to clarify longer term effects on long-term patientcentred outcomes including costs, amputation risk, and mortality. 100,127,128 For those with PAD, SET has improved 3-and 6-month maximum or pain-free walking distance compared with placebo, usual care, iloprost, or vitamin E, paralleled by a 3-month increase in ABI mainly for patients with ABI levels >0.5.…”

Long non‐coding RNA GAPLINC promotes angiogenesis by regulating miR‐211 under hypoxia in human umbilical vein endothelial cells

“…Critical limb ischaemia (CLI) is a clinical syndrome of ischaemia pain, rest pain, ischaemic ulceration and gangrene with a high risk of limb loss, cardiovascular disease and major amputation. It is considered to be the most fatal complications of peripheral artery disease (PAD) . Diabetes is among the high‐risk factors of PAD .…”

“…It is considered to be the most fatal complications of peripheral artery disease (PAD). 1 Diabetes is among the high-risk factors of PAD. 2 Currently, some of the treatment of CLI including vascular reconstruction, relieve pain and wound healing aimed at preventing limb amputation.…”

Determining End Points for Critical Limb Ischemia Interventions

“…1 This condition has reached epidemic proportions in recent years, in major part because of the continuous rise in the rates of diabetes mellitus and renal insufficiency. It is estimated that up to 23% of patients older than age 55 may suffer from peripheral arterial disease (PAD), including more than 8 million in the United States and greater than 200 million worldwide.…”