Chronic critical limb ischemia

Abstract

Background: Some 40 000 lower limb amputations are performed in Germany each year, 70% of them in diabetics. About 80% of all major amputations may be preventable with the use of new interventional and vascular surgical procedures, particularly on the arteries of the leg and foot. We present the current state of the art in revascularization techniques and evaluate their usefulness for preservation of the lower limb.

Methods: This overview is based on the guidelines for the diagnosis and treatment of peripheral artery disease (PAD) and diabetic foot syndrome (DFS) that have been issued by the American Heart Association (AHA), the American College of Cardiology (ACC), the German Society of Angiology (DGA), the Trans-Atlantic Intersociety Consensus (TASC II), the German Society of Vascular Surgery (DGG), and the German Diabetes Society (DDG). A selective search in PubMed for relevant articles that appeared from 2000 to 2011 was conducted with the search terms "pedal bypass," "vascular intervention crural pedal," and "crural-pedal revascularization."

Results: Most of the data on crural and pedal revascularization are derived from small-scale studies. The few comparative studies of interventional treatments and bypass surgery have not revealed any significant differences in outcome, but all studies of revascularization have shown good success rates for lower limb preservation.

Conclusion: Though the data are still sparse, the high reported rates of limb preservation imply that peripheral revascularization techniques can play a major role in the treatment of chronic critical limb ischemia (CLI). Therefore, these techniques are recommended without exception by the current guidelines.

Figures

Figure 1

Digital subtraction angiography of the arteries of the foot (a, anteroposterior; b, lateral)

Figure 2

Crural intervention (a, before; b, after percutaneous transluminal angioplasty)

Figure 3

Digital subtraction angiography of a popliteo-pedal bypass from the popliteal artery (P3) to the dorsal artery of the foot

Figure 4

Indications for crural/pedal bypass implantation or intervention. PAD, peripheral arterial disease; DFS, diabetic foot syndrome

Figure 5

Treatment strategy in critical limb ischemia (SCS, spinal cord stimulation)