Medical and Endovascular Management of Critical Limb Ischemia

Abstract

Critical limb ischemia (CLI) is the term used to designate the condition in which peripheral artery disease has resulted in resting leg or foot pain or in a breakdown of the skin of the leg or foot, causing ulcers or tissue loss. If not revascularized, CLI patients are at risk for limb loss and for potentially fatal complications from the progression of gangrene and the development of sepsis. The management of CLI requires a multidisciplinary team of experts in different areas of vascular disease, from atherosclerotic risk factor management to imaging, from intervention to wound care and physical therapy. In the past decade, the most significant change in the treatment of CLI has been the increasing tendency to shift from bypass surgery to less invasive endovascular procedures as first-choice revascularization techniques, with bypass surgery then reserved as backup if appropriate. The goals of intervention for CLI include the restoration of pulsatile, inline flow to the foot to assist wound healing, the relief of rest pain, the avoidance of major amputation, preservation of mobility, and improvement of patient function and quality of life. The evaluating physician should be fully aware of all revascularization options in order to select the most appropriate intervention or combination of interventions, while taking into consideration the goals of therapy, risk-benefit ratios, patient comorbidities, and life expectancy. We discuss the incidence, risk factors, and prognosis of CLI and the clinical presentation, diagnosis, available imaging modalities, and medical management (including pain and ulcer care, pharmaceutical options, and molecular therapies targeting angiogenesis). The endovascular approaches that we review include percutaneous transluminal angioplasty (with or without adjunctive stenting); subintimal angioplasty; primary femoropopliteal and infrapopliteal deployment of bare nitinol, covered, drug-eluting, or bioabsorbable stents; cryoplasty; excimer laser-assisted angioplasty; excisional atherectomy; and cutting balloon angioplasty.

An Overview of Optimal Endovascular Strategy in Treating the Femoropopliteal Artery: Mechanical, Biological, and Procedural Factors

“…Several excellent reviews have been written on the treatment of FP disease and the reader is encouraged to refer to these published manuscripts. [73][74][75][76][77][78] Over the past several years, data from small randomized and observational studies seem to support the strategy of balancing mechanical, biological, and procedural factors during FP arterial interventions. Improving vessel compliance is seen with debulking such as directional atherectomy or orbital atherectomy.…”

Are there sufficient standards for the in vitro hemocompatibility testing of biomaterials?

“…Atherosclerotic diseases still cannot be cured and, till today, about 50% of the population of industrial nations die from cardiovascular diseases. To restore sufficient blood flow in diseased arteries, balloon catheters with or without the implantation of endovascular stents [3,4] are routinely applied. These cardiovascular implants are selected and designed to be hemocompatible in order to fulfil their function.…”

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)

“…• Leczenie wewnątrznaczyniowe [320][321][322][323][324][325][326] • Klopidogrel preferowany w stosunku do ASA • "zespół naczyniowy" (vascular team) w celu prowadzenia wielodyscyplinarnego leczenia…”