Medical and endovascular management of critical limb ischemia.
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.
Lumsden
Alan B
AB
Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, 6550 Fannin Street, Suite 1401, Houston, TX 77030, USA. ablumsden@tmhs.org
Davies
Mark G
MG
Peden
Eric K
EK
D000671:Amputation, Surgical; D002317:Cardiovascular Agents / Q000009:adverse effects / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D016638:Critical Illness; D005121:Extremities / Q000098:blood supply*; D006801:Humans; D015994:Incidence; D007383:Intermittent Claudication / Q000209:etiology / Q000628:therapy; D007511:Ischemia / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D023821:Limb Salvage; D019060:Minimally Invasive Surgical Procedures; D010348:Patient Care Team; D016491:Peripheral Vascular Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D017410:Practice Guidelines as Topic; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects
D002317:Cardiovascular Agents