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)
Advantages	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
Disadvantages	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