Management of Critical Limb Ischemia

Management of Critical Limb Ischemia


Critical limb ischemia (CLI) refers to severe compromise of blood flow to alimb (hands or legs) which causes severe limb pain at rest or even loss of limb. It is the most advanced form of peripheral artery disease.

CLI numbers:

  • Prevalent in 2% patient over 70 years of age.
  • Within 1 year of diagnosis, 40-50% patientshave an amputation and 25% die.

How CLI leads to amputation?

Amputation occurs when there is marked ischemia of the limb owing to reduction of blood flow and increase demand in the limb.

Factors that reduce blood supply:

  • Diabetes mellitus
  • Severe Renal or Heart failure
  • Vasospastic diseases
  • Smoking

Factors that increase demand for blood flow:

  • Infection (cellulitis)
  • Skin breakdown
  • Trauma
  • Osteomyelitis

 Diagnosis of CLI:

Characteristic Duplex Ultrasound Digital – Subtraction Angiography Magnetic Resonance Angiography (MRA) Computed Tomographic Angiography (CTA)
  • Noninvasive
  • Can Visualize & Quantitate severity
  • Gold Standard
  • High Resolution
  • Can guide intervention
  • Noninvasive
  • No radiation
  • No contrast
  • 3 D
  • Noninvasive
  • Higher Resolution than MRA
  • 3 D
  • Operator dependent
  • Limited by
    dense calcification
  • Invasive
  • Radiation
  • Contrast
  • 2Dimensional
  • Lower Resolution than CTA
  • Claustrophobia
  • Contrast Image artifact if stent present
  • Radiation (25% of dose with DSA)
  • Contrast
  • Limited by calcification

Management plan for critical limb ischemia:

Critical Limb Ischemia Non-Healing Ulcer Rest Pain

MRA, CTA or invasive argiography shows lesion treatable by endovascular approach

  • Endovascular revascularization ->Wound care and atherosclerosis risk factor modification
  • Lesion treatable by open sugery at acceptable operative risk
    • Surgical revascularization ->Wound care and atherosclerosis risk factor modification
    • Consider primary amputation ->Wound care and atherosclerosis risk factor modification



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