Critical limb ischemia

By
Dr.Sifatullah
PGT Gen.Surgery
Critical limb ischemia

• PAD/PVD- refers to obstruction or deterioration of arteries other

than those supplying the heart and with in the brain`
•
Critical limb ischemia refers to the clinical state of advanced
arterial occlusive disease , placing an extremity at risk for
gangrene and limb loss.
•
CLI is a progressive evolution & clinical manifestation of PAD.
CLTI Definition

• The term Critical Limb Ischemia (CLI) is out-dated and fails to

encompass the full spectrum of patients who are evaluated and
treated for limb-threatening ischemia in modern practice

• Instead, the term Chronic Limb-Threatening Ischemia (CLTI) is

proposed, to include a broader and more heterogeneous group of
patients with varying degrees of ischemia that can often delay
wound healing and increase amputation risk.
Outlines

• Chronic limb threatening ischemia ( CLTI)

• Definition
• Prevalence
• Risk factors
• Natural history
• Diagnosis
• Classification
• Treatment and importance of limb salvage
Definition

• Spectrum of disease that includes patients with objectively

documented PAD and any of the following:

Ischemic rest pain with confirmatory hemodynamic studies

Non-healing lower limb or foot ulceration of at least 2 weeks duration
• Gangrene involving any portion of the lower limb or foot
Risk factors

• Smoking
• Diabetes
• HTN
• HLD
• Air pollution
• CKD/ESRD
• Obesity
• Sedentary lif style
Prevalence

• In 2013, Fowkes et al. undertook a meta-analysis of 34 studies to

compare the prevalence and risk factors between HICs and LMICs
• They concluded,
• “Globally, 202 million people were living with peripheral artery disease in 2010,
69.7% of them in LMIC, including 54.8 million in Southeast Asia and 45.9 million in
the Western Pacific Region.
• During the preceding decade, the number of individuals with peripheral artery
disease increased by 28.7% in LMIC and 13.1% in HIC.
• Also of note is the percentage of increase of PAD is higher in women than men in
LMIC which is opposite of HIC.” The increase in PAD burden observed in women
and in the younger, economically productive age groups is especially worrisome
Natural Hx of CLTI
Diagnostic Evaluation

• History
• Description/Duration of symptoms
• Ischemic rest pain usually affect the forefoot
• Neuropathy
• CV risk factors
• Drug history
• Previous vascular interventions
• Physical
• Non-invasive/invasive imaging
• For Final Dx and decision making about the treatment.
• History
• Physical
• Vascular exam begins with checking pulses
• Cap refil ( typical more than 5 sec)
• Cool dry skin
• Muscle atrophy
• Hair loss
• Imaging
Non invasive/invasive imaging

• Clinical examination remains the mainstay of initial diagnosis, with

noninvasive physiologic testing followed by duplex and CTA/MRA if needed.
• Classify the disease
• to determine the anatomical pattern of the disease and the TAP
(Target Artery Pathway)
• To make decision about the preferred choice of treatment

• The following flowchart outlines the diagnostic evaluation of the

patient with CLTI.
• Once the patient is deemed to be a candidate for
revascularization, further evaluation is required to
determine the anatomical pattern of the disease
and the TAP (Target Artery Pathway)
The PLAN

• Patients with CLTI are at high risk for both limb and life loss.
• Limb salvage depends on effective revascularization of the threatened
limb and this decision depends on multiple factors including patients’
risk stratification, status of the limb, and anatomical pattern of the
disease, which would lend itself to effective revascularization.
•  new three-step integrated approach is suggested to
facilitate decision-making in every day clinical practice
and future research.
• PLAN
• P : Patient Risk estimation
• L : Limb threat severity: WIfI Staging (SVS-threatened limb classification)
1. An: Anatomic pattern of disease: GLASS (Global Anatomical Staging
System).
Patient risk

• CLTI is associated with advanced age, multiple comorbidities, and

increased risks with revascularization without adequate
preoperative assessment.
• Several tools for risk stratification are available.
• Although majority of patients should be considered for limb saving
revascularization, few may be better served with primary
amputation or conservative management, after risk stratification.
P L AN: Limb threat
severity

WIFi classification
Classification of Disease

• The use of multiple classifications system (Rutherford, Fontaine,

Wagner,TASC) has hindered the development of treatment
algorithms given the heterogeneity amongst the commonly used
systems.

• Historic classifications tend to focus more on pure hemodynamic or

anatomic features.
• Ischemia-dominant models do not appreciate the absolute perfusion that
needs to be considered in diabetic patients with underlying neuropathic
changes.
WIFi classification

• SVS WIFi Index

• Wound :Extent and depth

• Ischemia : perfusion/flow
• Foot infection : Presence and extent

• 4 scale
• 0 : none
• 1 : mild
• 2 : moderate
• 3 : severe
WIFI INDEX

• 2nd table
Global Limb Anatomical Staging System

(GLASS)
In the recent past, a clinically oriented framework for classifying the
pattern of arterial disease in CLTI has been proposed.
the Global Limb Anatomic Staging System (GLASS) serves to estimate
the chance of success and patency of arterial pathway revascularization
based on the extent and distribution of the atherosclerotic lesions
GLASS separately scores the femoropopliteal (FP) and infrapopliteal
(IP) segment based on stenosis severity, lesion length and the extent
of calcification within the target artery pathway (TAP)
Disease distribution
Proposed treatment based on severity

• Graph
Treatment for PAD/CLTI

• Medical therapy-Everytime!!!
• Smoking cessation
• Excercise (supervised)
• HTN management (less than130/80)
• Diabetes management ( HbA1c less than 7)
• Anti platelet therapy
• ASA, clopidogrel,dual anti-platlet therapy)
• Statin therapy
• Rivaroxaban ?? ( COMPASS and VOYAGER trials)

• Surgical Therapy
• Endovascular – angioplasty +/- stent
• Open reconstruction
• Bypass
• Endarterectomy
 Cont ...

• Pic
Endovascular therapy

1- obtain arterial access & perform angiography

2- pass a guidewire beyond areas of stenosis or occlusion
3-Confirm that the guide wire in lumen of distal arterial line
4-Perform angioplasty, stent placement ( if residual stenosis or if
presence of dissection) or arterectomy over guide wire
5- Confirm success of results with completion angiography
Cont..

• 1-2 % pts have risk of complications at access site

• Bleeding ( refractory case after reversal with tense hematoma on
skin or transfusion requirement >4U of PRBC need surgical arterial
repair)
• Pseudoaneurysm ( > 2cm size can b managed by sono guided
thrombin injection 1000U in 3ml NS)
• Arterial dissection (managed by surgical endarterectomy)
Open surgery therapy

• Surgical bypass

• long segment occlusive disease

• A native vein or prosthetic material is used for bypassing the obstruction

• Bypass proceedure is classified to

• Anatomic , eg-femoropopliteal bypass
• Extra anatomic- femorofemoro crossover graft, iliofemoral crossover graft,
axillobifemoral graft.
complications

• • Open sx have fairly high mortalit

• Wound complication ( 20 %)
• Persistent edema (20 %) in 1 yr
• Graft thrombosis 10 %
• Major amputations 10 %
• Graft infection 1-2 %
Hybrid surgical therapy

• Combination of endovascular and open surgery

For pt with critical limb ischemia with short segment lesion in one
anatomic distribution and more advanced in another segment

• sugery vs Endo vascular

• Endovascular is having decreased morbidity
•Surgical rx have more durability of reconstruction ( 5 yr patency is > 75 %)
•For endo vascular 2 yr primary patency is 28 %, secondary patency with
percut re intervention is >80%
• Limb salvage rate is same for both
Post vascularization surveillance

 
• Serial arterial duplex and ABI with digital pressures

• Duplex scan at 1, 3, 6, and 12 months and every 6 months

• Angioplasty and stent site restenosis

End of presentation

• Thank you