Should an 80-year-old female patient with advanced PAD and CLI be referred for vascular surgery and started on aspirin and a statin, such as atorvastatin?

Management of Critical Limb Ischemia in an 80-Year-Old Female

This patient with critical limb ischemia (CLI) should be urgently referred to vascular surgery for revascularization evaluation, and should be started on both aspirin 75-100mg daily and high-intensity statin therapy to reduce cardiovascular and limb events. 1

Clinical Assessment and Diagnosis

The patient presents with:

• Chronic left ankle ulcer since May 2025
• Bilateral high-grade atherosclerotic stenosis of supragenicular popliteal arteries
• Thrombosis of both posterior tibial arteries with collateral reconstitution
• Patent aorta and iliac/femoral vessels
• Advanced peripheral arterial disease (PAD) with critical limb ischemia

These findings represent critical limb ischemia, which without treatment typically leads to major limb amputation within 6 months 2.

Vascular Surgery Referral

Urgent vascular surgery referral is mandatory for this patient because:

• CLI represents a vascular emergency requiring specialist assessment 2
• The patient has skin breakdown (ankle ulcer) which requires specialized wound care expertise 2
• Without revascularization, most CLI patients require amputation within 6 months 2
• The angioscan shows potentially revascularizable lesions (bilateral popliteal stenosis)

Pharmacological Management

Antiplatelet Therapy

• Start aspirin 75-100mg daily as first-line antiplatelet therapy 1
• Consider clopidogrel 75mg daily as an alternative if aspirin is not tolerated, as it shows 23.8% better reduction of cardiovascular events compared to aspirin in PAD patients 1

Lipid Management

• Start high-intensity statin therapy regardless of baseline LDL levels 1
• Target LDL-C < 1.4 mmol/L (55 mg/dL) and >50% reduction from baseline 1
• Statin therapy is associated with reduced cardiovascular events (hazard ratio 0.76) 3

Additional Management Considerations

Wound Care

• Refer to healthcare providers with specialized expertise in wound care 2
• Systemic antibiotics should be initiated promptly if there's evidence of infection 2

Risk Factor Modification

• Blood pressure management: target <140/90 mmHg for non-diabetic patients and <130/80 mmHg for diabetic patients 1
• Diabetes management: target HbA1c <7% if diabetic 1
• Smoking cessation if applicable 1

Revascularization Options

The optimal revascularization strategy must be determined by the vascular surgeon based on:

• The patient's overall health status and surgical risk
• Anatomical distribution of disease (already identified on angioscan)
• Technical feasibility of endovascular or open surgical approaches

For this patient with popliteal stenosis and tibial artery thrombosis:

• Endovascular therapy may be preferred given her advanced age (80 years) and potentially higher surgical risk 4
• Surgical bypass remains an option if endovascular approach is not feasible 5

Follow-up and Monitoring

After initial management:

• Regular foot examination with shoes and socks removed 2
• Evaluation at least twice annually by a vascular specialist due to high recurrence risk 2
• Monitoring for cardiovascular events, as CLI patients have high cardiovascular event rates 3

Common Pitfalls to Avoid

1. Delaying referral: CLI is a limb-threatening condition requiring urgent specialist assessment
2. Neglecting medical therapy: Even with planned revascularization, antiplatelet and statin therapy are essential
3. Focusing only on the limb: CLI indicates systemic atherosclerosis requiring comprehensive cardiovascular risk management
4. Inadequate wound care: Specialized wound care is crucial alongside vascular interventions
5. Overlooking patient education: Patients need clear instructions on foot care and when to seek urgent attention

In summary, this patient requires urgent vascular surgery referral, immediate initiation of aspirin and statin therapy, specialized wound care, and comprehensive cardiovascular risk management to optimize limb salvage and reduce mortality risk.