Management of Critical Limb Ischemia

Abstract

Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as nonhealing ulcers or gangrene, related to peripheral artery disease. CLI has a high short-term risk of limb loss and cardiovascular events. Noninvasive or invasive angiography help determine the feasibility and approach to arterial revascularization. An endovascular-first approach is often advocated based on a lower procedural risk; however, specific patterns of disease may be best treated by open surgical revascularization. Balloon angioplasty and stenting form the backbone of endovascular techniques, with drug-eluting stents and drug-coated balloons offering low rates of repeat revascularization. Combined antegrade and retrograde approaches can increase success in long total occlusions. Below the knee, angiosome-directed angioplasty may lead to greater wound healing, but failing this, any straight-line flow into the foot is pursued. Hybrid surgical techniques such as iliac stenting and common femoral endarterectomy are commonly used to reduce operative risk. Lower extremity bypass grafting is most successful with a good quality, long, single-segment autogenous vein of at least 3.5-mm diameter. Minor amputations are often required for tissue loss as a part of the treatment strategy. Major amputations (at or above the ankle) limit functional independence, and their prevention is a key goal of CLI therapy. Medical therapy after revascularization targets risk factors for atherosclerosis and assesses wound healing and new or recurrent flow-limiting disease. The ongoing National Institutes of Health-sponsored Best Endovascular Versus Best Surgical Therapy in Patients With Critical Limb Ischemia (BEST-CLI) study is a randomized trial of the contemporary endovascular versus open surgical techniques in patients with CLI.

Keywords: angioplasty, balloon; drug-eluting stent; endarterectomy; endovascular techniques; peripheral arterial disease.

© 2016 American Heart Association, Inc.

Figures

Figure 1

Overlap in TcO2 and toe pressure results between patients requiring revascularization or amputation for CLI and patients managed medically. From data in Ubbink, et al

Figure 2

Suggested algorithm for the approach to revascularization in patients with critical limb ischemia.

Figure 3

Approach for arterial access for endovascular revascularization of the lower limbs.

Figure 4

Intravascular ultrasound used to assess the intra-arterial location while traversing a long occlusion. A. The IVUS catheter (C) is seen over a looped wire in an occluded segment of the mid superficial femoral artery. An adjacent wire is extra-arterial. SFA indicates the distal superficial femoral artery beyond the occlusion. B. IVUS image showing the catheter (C) in the middle of the artery and adjacent to the femoral vein (FV). The diameter of the artery was 6.1 × 6.2 mm, which represents to media and intima and likely overestimates the reference lumen diameter. C. Stent deployment after successfully traversing the occluded artery. D. Final result on angiography.

Figure 5

Combined antegrade access from the left femoral artery and retrograde access from the left peroneal artery in a patient with an occluded left popliteal artery and peroneal tibial trunk artery. A. Digital subtraction angiogram showing the occluded popliteal artery (Pop) with reconstitution of the peroneal artery. The posterior tibial artery (PT) is also reconstituted by is occluded shortly after its origin. The anterior tibial artery is completely occluded proximally. B. A road map image overlaying the distal peroneal artery to enable access of the peroneal artery in the mid calf with a needle (N). C. The needle and 0.014″ wire are advanced up the peroneal artery. D. The distal end of the wire (W) is penetrating the distal occlusion of the peroneal tibial trunk. E. A 0.025″ wire crosses the popliteal occlusion in a retrograde direction. F. The wire is snared from above through the femoral sheath. G. Both the proximal and distal ends of the wire were held taught to advance a balloon into the occlusion prior to dilation. I The popliteal artery after deployment of a self-expanding stent. J. Antegrade flow is restored in the peroneal artery after deployment of a short drug-eluting coronary stent at the distal margin of the popliteal stent.

Figure 6

Angiosome distributions showing regions supplied by each of the three below knee arteries.