In what scenarios can a patient with Chronic Limb-Threatening Ischemia (CLTI) follow up as an outpatient?

Outpatient Follow-Up for CLTI Patients

Patients with CLTI can follow up as outpatients after successful revascularization once wounds are healing and hemodynamic parameters are stable, with structured surveillance protocols based on the type of revascularization performed. 1

Post-Revascularization Outpatient Follow-Up Scenarios

After Bypass Surgery

• Initial outpatient visit should occur within 4-6 weeks of discharge, followed by visits at 3,6,12, and 24 months 1
• Clinical examination, ABI (or TBI) measurement, and duplex ultrasound (DUS) should be performed at each visit 1
• After 12 months, if the graft remains uneventful, late complications become rare (first-year vein graft stenosis incidence is 20%) 1
• Annual follow-up with a vascular physician expert in CLTI management is warranted long-term 1

After Endovascular Treatment

• Surveillance protocol differs from surgery because restenosis rates remain constant for at least 5 years (>50% in infra-popliteal arteries, 5% in pelvic region) with no plateau phase 1
• Clinical assessment for recurrent symptoms, ABI measurement, and DUS should be performed based on initial post-procedure findings 1
• If initial DUS is normal, repeat DUS only if symptoms reappear 1
• If initial DUS is abnormal, closer follow-up or re-intervention should be considered on a case-by-case basis 1
• Post-procedural ankle duplex-based ABI <0.90 predicts suboptimal wound healing and need for target lesion revascularization 1

Wound Healing Phase Requirements

Closer follow-up and wound care are required until complete healing occurs, after which transition to annual surveillance is appropriate 1. This is a critical distinction—patients cannot transition to routine outpatient follow-up while wounds remain unhealed.

Essential Components of Outpatient Follow-Up

At each outpatient visit, assessment must include: 1

• Clinical and hemodynamic status (ABI/TBI measurements)
• Functional status and limb symptoms
• Foot condition examination (checking for new ulcers or tissue breakdown)
• Medication adherence (antiplatelet therapy, statins, antihypertensives)
• Cardiovascular risk factors (blood pressure, lipids, glycemic control, smoking status)
• Availability for toe pressure (TP) and TcPO2 measurements if needed 1

Critical Pitfalls and Contraindications to Outpatient Management

Patients Who Should NOT Follow Up Outpatient

Patients with active, non-healing wounds require closer monitoring until healing is achieved 1. The following scenarios mandate more intensive follow-up or inpatient management:

• Recurrent ischemic rest pain suggesting revascularization failure 1
• New or worsening neurological deficits (sensory loss or motor deficit) 1
• Signs of graft thrombosis or acute limb ischemia 1
• Infectious complications requiring IV antibiotics or surgical debridement 1
• Hemodynamic deterioration (ankle pressure <50 mmHg, TP <30 mmHg, TcPO2 <30 mmHg) 1

Importance of Follow-Up Adherence

Nonadherence with vascular follow-up is associated with significantly higher 1-year mortality (40.9% vs. 15.6%) 2. Risk factors for nonadherence include:

• Transfer from another institution (OR 3.7) 2
• Lack of a primary care provider (OR 14.6) 2

These patients require care coordination through a primary care provider and direct referral to vascular surgery to improve follow-up adherence 2.

Long-Term Surveillance Rationale

CLTI patients have more than two-fold higher all-cause mortality and MI rates compared to unselected PAD patients 1. The post-revascularization period carries increased risk of major adverse limb events (MALE) and major adverse cardiovascular events (MACE) 1. Regular outpatient surveillance focuses on:

• Prevention of revascularization failure 1
• General cardiovascular condition monitoring 1
• Contralateral limb status assessment 1
• Detection of disease progression above or below the revascularization site 1