Introduction

Chronic Critical Limb Ischemia (CCLI) is the end

result of arterial occlusive disease, most commonly
atherosclerosis

Atherosclerosis causes of CCLI association with
diabetes (important risk faktor), HT,
hypercholesterolemia, smoking, thromboangititis
obliterans, Burgers disease and some forms of
arteritis

CCLI is a marker for premature death with mortality
rates of 25% at one year, 31,6% at two years and
excess of 60% after three years
Introduction
In diabetes patients :
atherosclerosis develops at a younger
age and progresses rapidly
Atherosclerosis affects more distal
vessels (profunda femoris, popliteal
and tibial arteries)

Atherosclerosis in distal arteries in
combination with diabetic neuropathy
contributes to the higher rates of limb
loss in diabetic patients compared
nondiabetic patients
Clinical Presentation CCLI
The development of CCLI
usually requires multiple sites
of arterial obstruction that
severely reduce blood flow
the tissues

CCLI due to critical tissue
ischemia is manifested
clinically as rest pain,
nonhealing wounds or tissue
necrosis (gangrene)
The European Working Group on Critical
Limb Ischemia Definition

Management of CCLI
Limb preservation should be the
goal in most patients with critical
limb ischemia.

Conservative treatment
Operative intervention :
revascularization and amputation
Follow-up regimen
Conservative Treatment CCLI
Risk factor modification :
Smoking cessation, blood pressure
control, good glycemic control and
reduction of lipid levels
Antiplatelet therapy :
Decrease the risk of myocardial
infarction, stroke and death
Reduces the rate of arterial reocclusion
after angioplasty or bypass


FIGURE 1A. Right heel ulcer in a 56-year-old
patient with diabetes. The ulcer failed to heal
after three months of conservative treatment.
CASE-1
FIGURE 1B. Segmental pressures and ankle-brachial index (ABI) in the same patient as
in Figure 1a. The ABI of 0.58 on the right and the pulsatile monophasic waveform in the
posterior tibial artery suggested that the ulcer could heal with conservative therapy.
CASE-1

FIGURE 1C. The patient
underwent operative
debridement and began a
regimen of dressing changes
(gauze dampened with normal
saline) three times a day. He
also began wearing a shoe
that allowed ambulation
without direct pressure on the
ulcer. He was followed weekly
in the outpatient clinic.

FIGURE 1D. The ulcer shows
good progress in healing after
three weeks of conservative
therapy.

FIGURE 1E. After
six weeks of
outpatient
treatment, the ulcer
is well healed
CASE-1