Critical Limb Ischemia

Critical Limb Ischemia (CLI) refers to severe impairment of blood flow in the lower extremities that is associated with impending tissue loss. Patients with CLI often have ulceration and gangrene. The development of such extensive vascular insufficiency is often a gradual process, and in many patients, peripheral arterial disease (PAD) is present for many years before the onset of CLI. Patients often have associated diabetes, hypertension, hyperlipidemia and a smoking history.
A simple skin ulcer or sore is usually the start of CLI. When blood flow is impaired, there is delayed healing. Bacterial infection can set in, and can even result in a systemic illness that can be fatal. The initial treatment includes good wound care and antibiotics. Evaluation of the vascular bed with an ultrasound can be useful to determine the extent of disease. In order to facilitate healing, revascularization is a priority. An angiogram is necessary to identity the anatomy.
If the anatomy is approachable by a percutaneous route, a simple balloon angioplasty may be enough to save the limb. In severe cases where gangrene is present an amputation and revascularization is often needed. If there is significant arterial narrowing and an amputation is performed there is a major risk that the wound will not heal and additional tissue loss will occur.
Patients with PAD are certainly at risk for limb loss but are also at risk for heart attack and stroke. Patients with PAD are six times more likely to die from a cardiovascular cause over a 10-year period. The risk of death is related to the same atherosclerotic process occurring in the legs as the build up of plaque in the arteries of the heart often results in an abrupt clot to form causing a myocardial infarction. After PAD is identified, patients should be treated as though they have coronary artery disease. Standard treatment includes cholesterol-lowering medications, aspirin and or Plavix, blood pressure control and smoking cessation.