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Critical limb ischemia

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Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

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  • Patients with critical limb ischemia (CLI) present with ischemic rest pain or with tissue loss. Tissue loss, in its mildest presentation, includes focal ischemic ulcer-ation or nonhealing wounds. Gangrene is the manifestation of severe chronic ischemia. Without revascularization, patients with CLI are at risk for limb loss and for potentially fatal complications from the progression of gangrene and the devel-opment of sepsis. The best patient outcomes are achieved when the diagnosis and appropriate treatment for CLI are not delayed.

  • Simple noninvasive tests, such as measurement of ankle-to-brachial indices or toe Doppler pressures, take only minutes to provide sufficient information to confirm the diagnosis of peripheral artery disease (PAD) and to document the severity of limb ischemia. Subsequent diagnostic imaging studies, such as arteriography, magnetic resonance angiography, or ultrasound duplex scanning, provide the detailed information needed to plan revascularization therapy.

  • Balloon angioplasty and stenting work best for focal segments of narrowing or short occlusions of the iliac arteries, but endovascular treatments yield progres-sively poorer results with longer and more distal lesions. Long segments of occlu-sion, especially those distal to the common femoral artery, are best treated with surgical bypass.

  • Pharmacotherapy and adjunctive therapies, such as topical therapies or hyperbaric oxygen treatment, may have a limited role in patients in whom revascularization procedures have failed or for those in whom revascularization is not technically possible\3-particularly when amputation is the only alternative. Prostanoids are the best-studied class of drugs for such applications, but their use is still investi-gational in the United States. Though other medical approaches, such as use of other vasoactive agents, drugs that treat claudication, or gene-induced angio-genesis may prove useful, they do not yet have demonstrated roles in the treatment of patients with CLI.

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References and Recommended Reading

  1. Dormandy JA, Rutherford RB: Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg 2000, 31:S1-S296. This comprehensive review was the product of a collaborative effort of 14 specialist societies in North America and Europe. The consensus assessments and recommendations reflect the current best knowledge and practice standards for the care of patients with PAD.

    Article  PubMed  CAS  Google Scholar 

  2. Jonason T, Ringqvist I: Factors of prognostic importance for subsequent rest pain in patients with intermittent claudication. Acta Med Scand 1985, 218:27–33.

    Article  PubMed  CAS  Google Scholar 

  3. Jonason T, Bergstrom R: Cessation of smoking in patients with intermittent claudication. Effects on the risk of peripheral vascular complications, myocardial infarction and mortality. Acta Med Scand 1987, 221:253–260.

    Article  PubMed  CAS  Google Scholar 

  4. Dormandy JA, Murray GD: The fate of the claudicant—a prospective study of 1969 claudicants. Eur J Vasc Surg 1991, 5:131–133.

    Article  PubMed  CAS  Google Scholar 

  5. Strandness DE Jr, Sumner D: Hemodynamics for Surgeons. New York: Grune & Stratton; 1975:278–281.

    Google Scholar 

  6. Bendick PJ, Glover JL, Kuebler TW, Dilley RS: Progression of atherosclerosis in diabetics. Surgery 1983, 93:834–838.

    PubMed  CAS  Google Scholar 

  7. Gensler SW, Haimovici H, Hoffert P, et al.: Study of vascular lesions in diabetic, nondiabetic patients. Clinical, arteriographic, and surgical considerations. Arch Surg 1965, 91:617–622.

    PubMed  CAS  Google Scholar 

  8. Bild DE, Selby JV, Sinnock P, et al.: Lower-extremity amputation in people with diabetes. Epidemiology and prevention. Diabetes Care 1989, 12:24–31.

    Article  PubMed  CAS  Google Scholar 

  9. Caputo GM, Cavanagh PR, Ulbrecht JS, et al.: Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994, 331:854–860. Highlights the importance of avoiding life- and limb-threatening complications in patients with diabetes. Glycemic control may retard the development of neuropathy, a major risk factor for the development of ulceration.

    Article  PubMed  CAS  Google Scholar 

  10. Ubbink DT, Kitslaar PJ, Tordoir JH, et al.: Skin microcirculation in diabetic and non-diabetic patients at different stages of lower limb ischaemia. Eur J Vasc Surg 1993, 7:659–656.

    Article  PubMed  CAS  Google Scholar 

  11. Fagrell B, Lundberg G: A simplified evaluation of vital capillary microscopy for predicting skin viability in patients with severe arterial insufficiency. Clin Physiol 1984, 4:403–411.

    PubMed  CAS  Google Scholar 

  12. Lipsky BA, Berendt AR: Principles and practice of antibiotic therapy of diabetic foot infections. Diabetes Metab Res Rev 2000, 16(suppl 1):S42-S46.

    Article  PubMed  Google Scholar 

  13. McIntyre KE: Control of infection in the diabetic foot: the role of microbiology, immunopathology, antibiotics, and guillotine amputation. J Vasc Surg 1987, 5:787–790.

    Article  PubMed  CAS  Google Scholar 

  14. Cunha BA: Antibiotic selection for diabetic foot infections: a review. J Foot Ankle Surg 2000, 39:253–257. Informative review.

    Article  PubMed  CAS  Google Scholar 

  15. Brodsky JW, Schneidler C: Diabetic foot infections. Orthop Clin North Am 1991, 22:473–489.

    PubMed  CAS  Google Scholar 

  16. Zierler RE, Zierler BK: Duplex sonography of lower extremity arteries. Semin Ultrasound CT MR 1997, 18:39–56.

    Article  PubMed  CAS  Google Scholar 

  17. Koelemay MJ, Legemate DA, de Vos H, et al.: Can cruropedal colour duplex scanning and pulse generated run-off replace angiography in candidates for distal bypass surgery. Eur J Vasc Endovasc Surg 1998, 16:13–18.

    Article  PubMed  CAS  Google Scholar 

  18. Aly S, Sommerville K, Adiseshiah M, et al.: Comparison of duplex imaging and arteriography in the evaluation of lower limb arteries. Br J Surg 1998, 85:1099–1102.

    Article  PubMed  CAS  Google Scholar 

  19. Zierler RE: Vascular surgery without arteriography: use of duplex ultrasound. Cardiovasc Surg 1999, 7:74–82.

    Article  PubMed  CAS  Google Scholar 

  20. Brewster DC: Current controversies in the management of aortoiliac occlusive disease. J Vasc Surg 1997, 25:365–379.

    Article  PubMed  CAS  Google Scholar 

  21. Dalman RL, Taylor LM, Moneta GL, et al.: Simultaneous operative repair of multilevel lower extremity occlusive disease. J Vasc Surg 1991, 13:211–219; 219–221.

    Article  PubMed  CAS  Google Scholar 

  22. Perler BA, Williams GM: Does donor iliac artery percutaneous transluminal angioplasty or stent placement influence the results of femorofemoral bypass? Analysis of 70 consecutive cases with long-term follow-up. J Vasc Surg 1996, 24:363–369; 369–370.

    Article  PubMed  CAS  Google Scholar 

  23. Treiman GS, Ashrafi A, Lawrence PF: Incidentally detected stenoses proximal to grafts originating below the common femoral artery: do they affect graft patency or warrant repair in asymptomatic patients? J Vasc Surg 2000, 32:1180–1189.

    Article  PubMed  CAS  Google Scholar 

  24. Samson RH, Showalter DP, Yunis JP: Isolated femoropopliteal bypass graft for limb salvage after failed tibial reconstruction: a viable alternative to amputation. J Vasc Surg 1999, 29:409–412.

    Article  PubMed  CAS  Google Scholar 

  25. Jackson MR, Belott TP, Dickason T, et al.: The consequences of a failed femoropopliteal bypass grafting: comparison of saphenous vein and PTFE grafts. J Vasc Surg 2000, 32:498–504; 504–495.

    Article  PubMed  CAS  Google Scholar 

  26. Mills JL: P values may lack power: the choice of conduit for above-knee femoropopliteal bypass graft. J Vasc Surg 2000, 32:402–405.

    Article  PubMed  Google Scholar 

  27. Chew DK, Conte MS, Donaldson MC, et al.: Autogenous composite vein bypass graft for infrainguinal arterial reconstruction. J Vasc Surg 2001, 33:259–264; 264–255.

    Article  PubMed  CAS  Google Scholar 

  28. Illig KA, Moran S, Serletti J, et al.: Combined free tissue transfer and infrainguinal bypass graft: an alternative to major amputation in selected patients. J Vasc Surg 2001, 33:17–23.

    Article  PubMed  CAS  Google Scholar 

  29. Caps MT, Cantwell-Gab K, Bergelin RO, Strandness DE: Vein graft lesions: time of onset and rate of progression. J Vasc Surg 1995, 22:466–474; 475.

    Article  PubMed  CAS  Google Scholar 

  30. Cohen JR, Mannick JA, Couch NP, Whittemore AD: Recognition and management of impending veingraft failure. Importance for long-term patency. Arch Surg 1986, 121:758–759.

    PubMed  CAS  Google Scholar 

  31. Bandyk DF, Schmitt DD, Seabrook GR, et al.: Monitoring functional patency of in situ saphenous vein bypasses: the impact of a surveillance protocol and elective revision. J Vasc Surg 1989, 9:286–296.

    Article  PubMed  CAS  Google Scholar 

  32. Ho GH, Moll FL, Kuipers MM, et al.: Long-term surveillance by duplex scanning of nonrevised infragenicular graft stenosis. Ann Vasc Surg 1995, 9:547–553.

    Article  PubMed  CAS  Google Scholar 

  33. Lundell A, Lindblad B, Bergqvist D, Hansen F: Femoropopliteal-crural graft patency is improved by an intensive surveillance program: a prospective randomized study. J Vasc Surg 1995, 21:26–33; 33–24.

    Article  PubMed  CAS  Google Scholar 

  34. Berkowitz HD, Fox AD, Deaton DH: Reversed vein graft stenosis: early diagnosis and management. J Vasc Surg 1992, 15:130–141; 141–132.

    Article  PubMed  CAS  Google Scholar 

  35. Nehler MR, Moneta GL, Yeager RA, et al.: Surgical treatment of threatened reversed infrainguinal vein grafts. J Vasc Surg 1994, 20:558–563; 563–555.

    PubMed  CAS  Google Scholar 

  36. Taylor T, Stonebridge PA, Allan PL, et al.: Duplex ultrasound surveillance of infrainguinal bypass grafts: auditing the process. J R Coll Surg Edinb 1994, 39:297–300.

    PubMed  CAS  Google Scholar 

  37. Abou-Zamzam AM, Lee RW, Moneta GL, et al.: Functional outcome after infrainguinal bypass for limb salvage. J Vasc Surg 1997, 25:287–295; 295–287. Assesses the outcomes of patients after surgical revascularization for CLI using criteria specific to the objectives to infrainguinal bypass.

    Article  PubMed  Google Scholar 

  38. Dormandy JA: Prostanoid drug therapy for peripheral arterial occlusive disease—the European experience. Vasc Med 1996, 1:155–158.

    PubMed  CAS  Google Scholar 

  39. Dormandy J, Heeck L, Vig S: Peripheral arterial occlusive disease: clinical data for decision making. Introduction. Semin Vasc Surg Jun 1999, 12:95. Interesting report.

    CAS  Google Scholar 

  40. Isner JM, Walsh K, Symes J, et al.: Arterial gene therapy for therapeutic angiogenesis in patients with peripheral artery disease. Circulation 1995, 91:2687–2692.

    PubMed  CAS  Google Scholar 

  41. Isner JM, Pieczek A, Schainfeld R, et al.: Clinical evidence of angiogenesis after arterial gene transfer of phVEGF165 in patient with ischaemic limb. Lancet 1996, 348:370–374.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, 77030, Houston, TX, USA

    David L. Dawson MD & Ryan T. Hagino MD

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  1. David L. Dawson MD
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  2. Ryan T. Hagino MD
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Dawson, D.L., Hagino, R.T. Critical limb ischemia. Curr Treat Options Cardio Med 3, 237–249 (2001). https://doi.org/10.1007/s11936-001-0042-5

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