Revascularization Indications in Symptomatic PAD with Tissue Loss
In patients with chronic limb-threatening ischemia (CLTI) and tissue loss, revascularization is mandatory for limb salvage and should be performed when possible to minimize tissue loss. 1
Primary Indication: CLTI with Tissue Loss
Revascularization is a Class I indication (highest level) for all patients with CLTI presenting with nonhealing wounds, gangrene, or tissue loss. 1 The goal is to establish in-line blood flow to the foot through at least one patent artery to decrease ischemic pain, allow wound healing, and preserve a functional limb. 1
Critical Prerequisites Before Revascularization
- Early recognition of tissue loss and/or infection with immediate referral to a vascular team is mandatory (Class I recommendation). 1
- Assessment of amputation risk must be performed before determining the revascularization strategy. 1
- Evaluation by an interdisciplinary care team is required before considering amputation, except in life-threatening sepsis. 1, 2
Revascularization Strategy Based on Anatomy
Infra-popliteal Disease (Most Common in CLTI)
For infra-popliteal revascularization, bypass using the great saphenous vein is the gold standard (Class I, Level A evidence). 1 This approach provides superior long-term patency and limb survival, particularly in long occlusions of crural arteries. 1
Endovascular therapy can be first-line for stenotic lesions and short occlusions. 1 However, if the patient has increased surgical risk or lacks an autogenous vein, endovascular therapy can be attempted even for longer lesions. 1
Femoro-popliteal Disease
CLTI is rarely isolated to the superficial femoral artery; up to 40% of cases require inflow treatment. 1 If endovascular therapy is chosen first, landing zones for potential bypass grafts must be preserved. 1 When bypass surgery is selected, it should be as short as possible using saphenous vein. 1
Aorto-iliac Disease
CLTI is almost never related to isolated aorto-iliac disease. 1 Complete digital subtraction angiography down to the plantar arches is required for proper arterial network assessment. 1 Hybrid procedures (e.g., aorto-iliac stenting with distal bypass) should be encouraged in a one-step approach when necessary. 1
Timing and Urgency
Revascularization should be performed before any minor amputation to improve wound healing. 1, 3 Without revascularization, patients with CLTI face a 22% all-cause mortality rate and 22% major amputation rate at 12 months. 1
When Revascularization is NOT Indicated
Revascularization should not be performed in the following scenarios:
- Nonviable limb with irreversible tissue damage (Class III: Harm). 1
- Extensive necrosis or infectious gangrene in non-ambulatory patients with severe comorbidities - primary major amputation is preferred. 1, 3
- Life-threatening sepsis requiring immediate source control - amputation takes precedence. 2, 3
- Moribund patients - adequate analgesia and supportive measures may be the only appropriate option. 1
Special Considerations
Diabetic Patients
In patients with CLTI and diabetes, optimal glycemic control is mandatory (Class I recommendation). 1 Full-leg angiography down to the plantar arches is essential as these patients typically have extended infra-popliteal disease often associated with superficial femoral artery lesions. 1
Angiosome Concept
Angiosome-directed endovascular therapy may be reasonable for patients with CLTI and nonhealing wounds (Class IIb recommendation). 1 This approach targets the specific infrapopliteal artery directly responsible for perfusing the region with the nonhealing wound. 1 However, the primary goal remains establishing in-line flow to the foot through at least one patent artery. 1
Staged Approach
A staged approach to revascularization is reasonable in patients with ischemic rest pain (Class IIa). 1 For multilevel disease, inflow lesions are generally addressed first, with outflow lesions treated in the same setting or later if symptoms persist. 1 However, for patients with nonhealing wounds or gangrene, restoration of direct in-line flow to the foot should not be delayed. 1
Common Pitfalls to Avoid
- Never perform amputation without vascular team evaluation unless life-threatening infection is present. 1, 2
- Do not use prosthetic grafts for femoral-tibial bypass in claudication (Class III: Harm) due to very high rates of graft failure and amputation. 1
- Avoid surgical revascularization solely to prevent progression to CLTI in asymptomatic or claudication patients (Class III: Harm). 1
- Do not consider stem cell or gene therapy for CLTI patients (Class III recommendation). 1
- Never delay revascularization in tissue loss - early intervention improves limb salvage rates. 1
Pre-Revascularization Imaging
In CLTI patients with below-the-knee lesions, angiography including foot runoff should be performed prior to revascularization (Class IIa). 1 This comprehensive imaging explores all revascularization options and is essential for procedure planning. 1