Department of Cardiothoracic and Vascular Surgery McGovern Medical School / The University of Texas Science Center at Houston Memorial Hermann Heart & Vascular Institute

Zain Al Rstum, MD

Critical Limb Ischemia

Introduction

• Critical limb ischemia is defined as a clinical syndrome of ischemic pain at rest and ischemic tissue loss such as nonhealing ulcers or gangrene, related to peripheral artery disease (PAD) of the lower limbs

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Introduction

• It differs from acute limb ischemia, which is a sudden loss of limb perfusion (defined as within 14 days) typically caused by embolus or in situ thrombus

• Several weeks to months

• CLI is considered the “end stage” of peripheral arterial disease (PAD)

International Vascular Symposium Working Party Definition:

• Severe rest pain requiring opiate analgesia for at least 4 weeks,

and one of the following:

• Ankle pressure <40 mm Hg

• Tissue necrosis or digital gangrene

Comprehensive_Vascular_and_Endovascular_Surgery_Expert_Consult_-_Online_and_Print_2nd_Edition

Comprehensive_Vascular_and_Endovascular_Surgery_Expert_Consult_-_Online_and_Print_2nd_Edition

Natural History

• PAD affects 8 to 10 million Americans and is associated with a threefold to sixfold increased risk of cardiovascular morbidity and death compared with individuals without PAD

• Cardiovascular events such as myocardial infarction and stroke occur in 30% to 50% of patients over a 1-year period

• Amputation: occurs on 30% to 50% in the first year in patients with CLI who do not undergo revascularization

Management

• The primary goal is to preserve limb function

• Also, CV risk modification

• Imaging:

U/S, ABIs with SP, CTA, Angiography

Comprehensive_Vascular_and_Endovascular_Surgery_Expert_Consult_-_Online_and_Print_2nd_Edition

Trans-Atlantic Inter-Society Consensus (TASC II)

Endovascular Revascularization

• Endovascular therapy is perceived to be a less invasive form of therapy associated with good technical success and fair overall patency

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Endovascular Revascularization

• (Endovascular versus open surgery) will depend on anatomic factors, comorbidities, patient preference, and operator experience and skill

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Distal disease

Surgical Revascularization

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Vascular and Vein Associates

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Trials

• BEST-CLI

• Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL)

• Multiple Metanalysis

• A recent meta-analysis that reviewed infrapopliteal angioplasty in CLI patients was compared with a similar meta-analysis of popliteal-distal vein bypass grafts in a similar patient population

Journal of Vascular Surgery Volume 51, Issue 1, Pages 230-241 (January

2010)

Journal of Vascular Surgery Volume 51, Issue 1, Pages 230-241 (January

2010)

Thank You