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.
- 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
Factors that increase demand for blood flow:
- Infection (cellulitis)
- Skin breakdown
Diagnosis of CLI:
||Digital – Subtraction Angiography
||Magnetic Resonance Angiography (MRA)
||Computed Tomographic Angiography (CTA)
- Can Visualize & Quantitate severity
- Gold Standard
- High Resolution
- Can guide intervention
- No radiation
- No contrast
- 3 D
- Higher Resolution than MRA
- 3 D
- Operator dependent
- Limited by
- Lower Resolution than CTA
- Contrast Image artifact if stent present
- Radiation (25% of dose with DSA)
- 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