What is the management of chronic limb threatening ischemia?

Management of Chronic Limb Threatening Ischemia

Early recognition of tissue loss and/or infection and referral to a vascular team is mandatory to improve limb salvage in patients with chronic limb threatening ischemia (CLTI). 1

Definition and Risk Assessment

CLTI is characterized by:

• Ischemic rest pain (typically in forefoot)
• Diabetic foot ulcer
• Non-healing lower limb/foot ulceration ≥2 weeks
• Gangrene of foot/lower limb

Risk stratification should be performed using the WIfI classification system, which evaluates:

• Wound (W): Severity of tissue loss (0-3)
• Ischemia (I): Hemodynamic severity (0-3)
• foot Infection (fI): Extent of infection (0-3)

Objective hemodynamic criteria include:

• ABI <0.40
• Ankle pressure <50 mmHg
• Toe pressure <30 mmHg
• TcPO2 <30 mmHg

Management Algorithm

1. Initial Management

• Vascular Team Consultation: All CLTI patients must be managed by a vascular team including vascular physician, surgeon, and radiologist 1
• Optimal Medical Therapy:
  • Aggressive cardiovascular risk factor management
  • Strict glycemic control in diabetic patients (improves limb outcomes and reduces amputation rates) 1
  • Antiplatelet therapy
  • Statin therapy
  • Antihypertensive therapy as needed

2. Wound Care and Infection Control

• Offloading: Mechanical stress reduction is mandatory for wound healing 1
• Infection Management:
  • Oral antibiotics for mild infections
  • IV antibiotics for extensive infections with systemic signs
  • Longer antibiotic courses for osteomyelitis (confirmed by X-ray or MRA)
  • Antibiotics should be adapted according to tissue cultures 1
• Wound Dressings: Individualized treatments may include antimicrobial, silver, honey-based, or iodine-based dressings 1
• Advanced Therapies: Consider platelet-rich plasma, collagen, or negative pressure therapy in selected cases 1

3. Revascularization

Revascularization should be performed as soon as possible 1

Anatomical Considerations:

a) Aorto-iliac Disease:

• First choice: Endovascular approach with bare metal or covered stents
• Surgery: Reserved for extensive obstructions or failed endovascular procedures
• Consider hybrid procedures (one-step modality) for complex cases 1

b) Femoro-popliteal Disease:

• Revascularization strategy based on lesion complexity
• If endovascular approach chosen, preserve landing zones for potential bypass grafts
• For bypass surgery, use shortest possible route with saphenous veins 1
• In patients with low surgical risk and available autologous vein, bypass surgery is indicated for long (≥25 cm) lesions 1

c) Infra-popliteal Disease:

• Common in diabetic patients and those with CKD
• For short lesions: Endovascular therapy as first choice
• For long occlusions: Bypass with autologous vein offers superior long-term patency
• Consider endovascular approach in patients with high surgical risk or inadequate veins 1

Decision-Making Between Surgical vs. Endovascular Approach:

Favor Endovascular First:

• High surgical risk patients
• No suitable autologous vein available
• Limited life expectancy (<2 years)
• Comorbidities increasing surgical risk

Favor Surgical Bypass:

• Low surgical risk (<5% perioperative mortality)
• Good autologous vein available
• Life expectancy >2 years
• Long-segment disease (especially infra-popliteal)

Important Principles:

• Always use autologous veins as preferred conduit for infra-inguinal bypass 1
• In multilevel disease, eliminate inflow obstructions when treating downstream lesions 1
• Consider hybrid procedures when appropriate (e.g., common femoral artery endarterectomy plus endovascular treatment of inflow/outflow disease) 1, 2

4. Follow-up

• Regular follow-up is mandatory after revascularization 1
• Assess clinical, hemodynamic and functional status, limb symptoms, treatment adherence, and cardiovascular risk factors 1
• Consider duplex ultrasound assessment as needed 1

Special Considerations

No-Option CLTI

For patients with no revascularization options:

• Optimal pain management
• Aggressive wound care
• Note: Stem cell/gene therapy is NOT recommended for CLTI patients 1

Amputation Considerations

• Primary amputation should be considered in bedridden, demented, or frail patients 1
• Secondary amputation when revascularization fails and re-intervention is not possible
• Prefer infragenicular amputation when possible to preserve knee joint mobility 1

Pitfalls and Caveats

1. Delay in Treatment: Early recognition and prompt referral to vascular team is critical for limb salvage 1

2. Exercise Training: Lower-limb exercise training is contraindicated in patients with CLTI and wounds until ulcers are healed 1

3. Multilevel Disease: CLTI is rarely related to isolated lesions; comprehensive assessment of the entire arterial tree is essential 1

4. Diabetic Patients: Require special attention due to higher prevalence of infra-popliteal disease and increased risk of infection 1

5. Revascularization Timing: Streamlined clinical pathways with expedited revascularization (within 5 days for inpatients, 2 weeks for outpatients) may significantly reduce major amputation rates 3

6. Decision-Making: Shared decision-making is important, particularly when considering amputation, as patients often experience better-than-anticipated outcomes after amputation when properly selected 4