Critical limb ischemia.
Critical limb ischemia (CLI), defined as chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease, is the most advanced form of peripheral arterial disease. Traditionally, open surgical bypass was the only effective treatment strategy for limb revascularization in this patient population. However, during the past decade, the introduction and evolution of endovascular procedures have significantly increased treatment options. In a certain subset of patients for whom either surgical or endovascular revascularization may not be appropriate, primary amputation remains a third treatment option. Definitive high-level evidence on which to base treatment decisions, with an emphasis on clinical and cost effectiveness, is still lacking. Treatment decisions in CLI are individualized, based on life expectancy, functional status, anatomy of the arterial occlusive disease, and surgical risk. For patients with aortoiliac disease, endovascular therapy has become first-line therapy for all but the most severe patterns of occlusion, and aortofemoral bypass surgery is a highly effective and durable treatment for the latter group. For infrainguinal disease, the available data suggest that surgical bypass with vein is the preferred therapy for CLI patients likely to survive 2 years or more, and for those with long segment occlusions or severe infrapopliteal disease who have an acceptable surgical risk. Endovascular therapy may be preferred in patients with reduced life expectancy, those who lack usable vein for bypass or who are at elevated risk for operation, and those with less severe arterial occlusions. Patients with unreconstructable disease, extensive necrosis involving weight-bearing areas, nonambulatory status, or other severe comorbidities may be considered for primary amputation or palliative measures.
Schanzer
Andres
A
Conte
Michael S
MS
J Vasc Surg. 2009 Jul;50(1):54-60
19481407
J Vasc Surg. 2005 Oct;42(4):710-6
16242559
Am Heart J. 2002 Jun;143(6):961-5
12075249
J Endovasc Ther. 2006 Feb;13(1):1-11
16445313
Lancet. 2002 Aug 10;360(9331):427-35
12241713
J Vasc Surg. 2005 Sep;42(3):456-64; discussion 464-5
16171587
Eur Heart J. 2005 Sep;26(18):1903-9
15855189
J Vasc Surg. 2010 May;51(5 Suppl):69S-75S
20435263
J Vasc Surg. 2010 Jan;51(1):71-8
19939615
J Vasc Surg. 2008 Apr;47(4):774-781
18381138
J Vasc Surg. 2006 Apr;43(4):752-9
16616232
J Vasc Surg. 2009 Oct;50(4):769-75; discussion 775
19628361
Mol Ther. 2008 May;16(5):972-978
28178491
J Vasc Surg. 2010 May;51(5 Suppl):18S-31S
20435259
Eur Heart J. 2009 Jan;30(1):44-55
19028778
Eur Heart J. 2004 May;25(9):742-8
15120884
J Vasc Surg. 2008 Mar;47(3):543-9
18295105
J Vasc Surg. 2007 May;45(5):936-43
17360142
J Vasc Surg. 2009 Jun;49(6):1431-9.e1
19497502
J Vasc Surg. 2007 May;45(5):944-52
17391900
J Vasc Surg. 2010 May;51(5 Suppl):32S-42S
20435260
J Cardiovasc Surg (Torino). 2007 Aug;48(4):455-61
17653005
J Cardiovasc Surg (Torino). 2010 Feb;51(1):125-43
20081769
Eur Heart J. 1999 Mar;20(5):344-53
10206381
Circulation. 2006 Mar 21;113(11):e463-654
16549646
Vasc Endovascular Surg. 2005 Jan-Feb;39(1):15-23
15696244
J Vasc Surg. 2006 Apr;43(4):742-751; discussion 751
16616230
J Vasc Surg. 2008 Dec;48(6):1489-96
18829227
J Cell Biochem. 2009 Nov 1;108(4):753-61
19711369
Cardiovasc Intervent Radiol. 2009 May;32(3):424-35
19093148
J Vasc Surg. 2007 Dec;46(6):1191-1197
18154995
J Vasc Surg. 2008 May;47(5):975-981
18372148
Ann Surg. 2007 Sep;246(3):415-22; discussion 422-4
17717445
J Vasc Surg. 2010 May;51(5 Suppl):52S-68S
20435262
World J Surg. 2007 Jan;31(1):217-25; discussion 226-7
17171494
BMC Cardiovasc Disord. 2005 Jun 22;5:14
15972099
J Vasc Surg. 2007 Dec;46(6):1173-1179
17950564
J Vasc Surg. 2010 Jun;51(6):1419-24
20456908
J Vasc Surg. 2008 Jul;48(1):128-36
18502084
J Vasc Surg. 2006 Nov;44(5):977-83; discussion 983-4
17098529
J Vasc Surg. 2010 May;51(5 Suppl):5S-17S
20435258
J Vasc Surg. 1989 May;9(5):691-6; discussion 696-7
2724457
Circulation. 2008 Jul 1;118(1):58-65
18559703
Lancet. 2005 Dec 3;366(9501):1925-34
16325694
Vasc Med. 2008 Aug;13(3):209-15
18687757
Atherosclerosis. 1991 Apr;87(2-3):119-28
1854359
N Engl J Med. 1996 Dec 5;335(23):1713-20
8929262
Circulation. 2003 Oct 21;108(16):1933-8
14504183
J Vasc Surg. 2007 Jan;45 Suppl S:S5-67
17223489
BMJ. 1994 Jan 8;308(6921):81-106
8298418
N Engl J Med. 2008 Feb 14;358(7):689-99
18272892
Lancet. 2002 Jul 6;360(9326):7-22
12114036
BMJ. 2002 Jan 12;324(7329):71-86
11786451
J Vasc Surg. 2009 Jun;49(6):1416-25
19497500
J Vasc Surg. 2007 Dec;46(6):1180-90; discussion 1190
18154993
Mol Ther. 2002 Jul;6(1):127-33
12095313
J Vasc Surg. 2002 Mar;35(3):494-500
11877697
Ann Vasc Surg. 2003 Sep;17(5):492-502
12958672
Cochrane Database Syst Rev. 2003;(3):CD004001
12917998
J Vasc Surg. 2008 Jan;47(1):101-8
18178459
Ann Vasc Surg. 2010 Jan;24(1):57-68
19748222
J Vasc Surg. 2009 Dec;50(6):1462-73.e1-3
19897335
J Vasc Surg. 2010 May;51(5 Suppl):43S-51S
20435261
Hum Gene Ther. 2006 Jun;17(6):683-91
16776576
J Vasc Surg. 2007 Dec;46(6):1093-1101; discussion 1101-2
17950568
EuroIntervention. 2008 Aug;4 Suppl C:C63-6
19202699
Eur J Vasc Endovasc Surg. 1998 Mar;15(3):220-4
9587334
J Vasc Surg. 2008 Dec;48(6):1464-71
19118735
JAMA. 2007 Mar 21;297(11):1197-206
17374814
N Engl J Med. 1992 Feb 6;326(6):381-6
1729621
J Vasc Interv Radiol. 2004 Nov;15(11):1197-207
15525738
Circulation. 2009 Jan 6;119(1):123-30
19103988
J Vasc Surg. 2006 Mar;43(3):498-503
16520163
J Vasc Surg. 2006 Oct;44(4):747-55; discussion 755-6
16926083