Critical Limb Ischemia: An Expert Statement

Shishehbor MH, White CJ, Gray BH, et al.
Critical Limb Ischemia: An Expert Statement. J Am Coll Cardiol 2016;68:2002-2015.

The following are 10 key points to remember about this review article on critical limb ischemia (CLI):

  1. CLI is the most advanced form of peripheral arterial disease (PAD) and associated with significant morbidity, mortality, and health care resource utilization. It is defined as ischemic rest pain, tissue loss, or gangrene in the setting of PAD and hypoperfusion of the lower extremity.
  2. CLI is a complex disease process that requires a multidisciplinary team approach. This should include physicians with broad medical and interventional skills, wound care nursing experts, home health care providers, and other specialists.
  3. Although the ankle-brachial index (ABI) is central to a diagnosis of PAD, approximately 30% of CLI patients have near-normal or normal ABI (>0.90). In these cases, toe pressures may better correlate with infrageniculate arterial patency and CLI severity. Computed tomography angiography can be used to visualize the near-full extent of the lower extremity arterial bed and any occlusions or severe stenoses.
  4. Angiosomes are a connected set of collateral vessels (choke vessels) that are able to supply indirect flow to a vascular territory in the absence of direct arterial flow. Angiosome-direct revascularization may be associated with a significant reduction in major amputation risk and allow for faster healing.
  5. The primary goal of medical therapy is to prevent myocardial infarction, stroke, and death. Additionally, it may accelerate wound healing, prevent amputation, and improve quality of life. This should include regular exercise and smoking cessation, along with use of statin and antiplatelet and antihypertensive therapies. Use of cilostazol may significantly reduce restenosis rates in patients undergoing lower extremity endovascular therapy.
  6. In a recent Agency for Healthcare Research and Quality review of 20 studies (including the BASIL trial), there was no difference in all-cause mortality, amputation, and amputation-free survival between endovascular and surgical revascularization. The BASIL-2 study is currently ongoing, in which CLI patients with infrainguinal disease are randomized to surgery or any endovascular procedure.
  7. Despite technological advances to manage CLI with minimally invasive procedures, these techniques are often underutilized. This is particularly true for patients from lower socioeconomic backgrounds and nonwhite race.
  8. Drug-coated balloons have demonstrated superior patency as compared with angioplasty for femoral-popliteal arteries and sustained up to 5 years. An ongoing study is comparing drug coating ballon versus angioplasty alone in patients with CLI and infrapopliteal disease.
  9. While ischemic rest pain is typically associated with multilevel disease (both inflow and outflow), relief is often provided after revascularization of inflow disease only. Without revascularization, up to 40% of CLI patients will require limb amputation within 1 year.
  10. Ulcer formation is frequently multifactorial, involving pressure, trauma, venous insufficiency, congestive heart failure, and poor hygiene in addition to poor arterial perfusion.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: Amputation, Angiography, Angioplasty, Antihypertensive Agents, Constriction, Pathologic, Endovascular Procedures, Gangrene, Heart Failure, Ischemia, Lower Extremity, Myocardial Infarction, Myocardial Revascularization, Peripheral Arterial Disease, Popliteal Artery, Primary Prevention, Quality of Life, Smoking Cessation, Stroke, Tomography, Venous Insufficiency

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