Management of Critical Limb Ischemia

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Management of Critical Limb Ischemia

• From ACC/AHA Guidelines for the Management of PAD

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Critical Limb Ischemia

• 5P
• Pain
• Pulselessness
• Pallor
• Paresthesia
• Paralysis

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Medical treatment

• Class III
• PentoxifyllineI(Trental) is not useful.
• Class IIb
• IV PGE-1, or iloprost for 728 days reduce
  ischemic pain and facilitate ulcer healing,
  limited to small percentage of patients

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Endovascular Treatment

• Class I
• 1.Treat inflow lesions first
• 2.Treat outflow lesions if infection or
  symptoms persisted
• 3.Use vasodilator for augmentation of
  intra-arterial pressure measurement

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Thrombolysis

• Class I
• Catheter-based thrombolysis , with acute limb
  ischemia of less than 14 days
• Class IIa
• Mechanical thrombectomy, for adjunctive therapy
• Class IIb
• more than 14 days

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Surgery for Critical Limb Ischemia

• Patients with CLI in whom open surgical repair is
  anticipated should undergo assessment of
  cardiovascular risk.

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Consideration of surgery

• Relief of rest pain
• Healing of ulcers
• Prior revascularization attempts
• The type of procedure
• The patients overall ability to recover

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Primary amputation

• Significant necrosis of weight-bearing portions
  of the foot
• Uncorrectable flexion contracture
• Paresis of the extremity
• Refractory ischemic rest pain
• Sepsis
• Limited life expectancy

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Aortoiliac Occlusive Disease

• Aortobifemoral bypass
• Iliac endarterectomy, patch angioplasty, or
  aortoiliac or iliofemoral bypass
• Axillofemoral-femoral bypass
• Vein gt Prosthetic conduit
• Patency of prosthesis below knee ?

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Infrainguinal Disease

• Bypass to the above-knee or below-knee popliteal
  a. with autogenous v.
• The point of origin for bypass stenosis lt 20,
  most distal a.
• Femoral-tibial a. bypass with v.

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Infrainquinal disease

• Composite sequential femoropopliteal-tibial
  bypass, and bypass to an isolated popliteal a.
  segment
• Prosthetic femoral-tibial bypass
• Class IIa
• Prosthetic below-knee popliteal artery bypass

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Post surgical care

• Maximal cardiovascular ischemic risk reduction
  therapies
• Bypass all major distal stenosis and occlusions
  if symptoms persisted.
• F/U at least 2 years,
• Duplex for vein grafts
• ABI for synthetic grafts (0.91.3)

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Cardiovascular Risk Reduction

• a. Lipid-Lowering Drugs
• b. Antihypertensive Drugs
• c. Diabetes Therapies
• d. Smoking Cessation
• e. Homocysteine-Lowering Drugs
• f. Antiplatelet and Antithrombotic Drugs

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Lipid-Lowering Drugs

• Class I
• Statin, LDL lt 100
• Class Iia
• Statin, LDL lt 70 (high risk patients)
• Fibric acid derivative

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Antihypertensive Drugs

• Class I
• BP lt 140/90
• lt 130/80 (DM, CRD)
• Beta blockers are not contraindicated.
• Class IIa
• ACEI reduce risk of cardiovascular disease for
  symptomatic patients

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Diabetes Therapies

• Class I
• Foot care
• Class IIa
• HbA1c lt 7,
• for improve cardiovascular outcome
• reduce microvascular complication

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Smoking Cessation

• Class I
• Comprehensive smoking cessation intervention

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Homocysteine-Lowering Drugs

• Class IIb
• Folic acid and Vit.B12 for homocysteine gt 14
  µmole/l patients

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Antiplatelet and Antithrombotic Drugs

• Class I
• Aspirin 75325mg qd
• Clopidogrel 75mg qd
• reduce risk of MI, stroke, or vascular death
• Class III
• Warfarin is not indicated.