What is the recommended management for a patient with critical limb‑threatening ischemia (rest pain, tissue loss, or gangrene)?

Management of Critical Limb-Threatening Ischemia

In patients with critical limb-threatening ischemia (CLTI), immediate revascularization—either endovascular, surgical, or hybrid—is mandatory to minimize tissue loss, heal wounds, relieve pain, and preserve a functional limb. 1

Immediate Recognition and Referral

• Early recognition of CLTI and urgent referral to a vascular team are essential for limb salvage. 1 CLTI is defined by chronic ischemic rest pain, non-healing ulcers, or gangrene with objectively proven arterial occlusive disease. 2, 3
• Revascularization must be performed as soon as possible—delays directly increase amputation risk and mortality. 1, 4
• Before any amputation decision, an interdisciplinary care team evaluation is mandatory to assess all revascularization options. 1, 4

Medical Management While Arranging Revascularization

• Offloading mechanical tissue stress is required to allow wound healing in patients with ulcers. 1
• Adequate analgesia should be provided to control ischemic rest pain. 4
• Empiric antibiotics are indicated when infection is present: oral agents for localized infection, intravenous therapy for extensive infection with systemic signs. 4
• Lower-limb exercise training is contraindicated in patients with CLTI and wounds, as it worsens tissue ischemia. 1, 4

Arterial Imaging Strategy

• Urgent arterial imaging must be performed to delineate vascular anatomy prior to revascularization planning. 4
• Duplex ultrasound is acceptable as first-line imaging, with CTA, MRA, or catheter angiography selected based on local expertise, renal function, and urgency. 4

Revascularization Strategy: The Critical Decision

The choice between endovascular-first versus surgical-first revascularization depends on three key factors: available autogenous vein conduit, patient life expectancy, and anatomic complexity. 1, 4

For Patients WITH Good-Quality Autogenous Vein AND Life Expectancy > 2 Years:

• Surgical bypass is the preferred first-line strategy. 1, 4
• The BEST-CLI trial demonstrated lower rates of major adverse limb events or death with surgical revascularization when single-segment great saphenous vein was available. 4
• The BASIL trial showed significant reduction in amputation or death after 2 years with surgical bypass in this population. 4
• Bypass to popliteal or infrapopliteal arteries must be constructed with autogenous vein (preferably great saphenous vein). 1, 4
• Ultrasound mapping of the great saphenous vein is mandatory before selecting the revascularization approach. 1

For Patients WITHOUT Suitable Autogenous Vein OR Life Expectancy ≤ 2 Years:

• Endovascular revascularization is the preferred initial strategy. 4
• The BASIL trial demonstrated equivalent amputation-free survival between endovascular and surgical approaches at 2 years in this population. 4
• Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with non-healing wounds or gangrene. 1
• When suitable autogenous vein is unavailable and endovascular attempts have failed, prosthetic conduit can be used for bypasses to below-knee popliteal and tibial targets. 4

Special Consideration for Infrapopliteal Disease:

• The BASIL-2 trial found endovascular revascularization provided superior amputation-free survival in high-risk tibial disease, mainly due to fewer deaths, suggesting endovascular preference in this specific anatomic pattern. 4

Technical Revascularization Details

Endovascular Approach:

• Revascularize hemodynamically significant stenoses (>75% diameter reduction, or 50-75% with abnormal pressure gradients). 4
• In multilevel disease with rest pain alone, treat inflow lesions first; reassess and stage outflow interventions if symptoms persist. 1, 4
• In patients with non-healing wounds or gangrene, restoration of direct in-line flow to the foot is essential for wound healing. 1
• Angiosome-directed revascularization may be considered to enhance wound healing, though supporting evidence is low-quality. 1, 4
• In femoropopliteal lesions, drug-eluting treatment should be considered as first-choice strategy. 1

Surgical Approach:

• In multilevel vascular disease, eliminate inflow obstructions when treating downstream lesions. 1
• For combined inflow and outflow disease, inflow lesions must be addressed first; if CLI symptoms persist after inflow revascularization, proceed to outflow bypass. 1, 4
• In CLTI patients with good autologous veins and low surgical risk (<5% peri-operative mortality, >50% 2-year survival), infra-inguinal bypass may be considered. 1

Post-Revascularization Management

• Regular follow-up is mandatory to assess clinical, hemodynamic and functional status, limb symptoms, treatment adherence, and cardiovascular risk factors. 1
• Aggressive off-loading must be instituted after revascularization to promote ulcer healing. 4
• Autogenous-vein bypasses require periodic clinical assessment, pulse examination, and duplex ultrasound of the entire graft for at least 2 years. 4
• Synthetic bypasses should be monitored with symptom review, pulse checks, and ankle-brachial index measurements at rest and after exercise for a minimum of 2 years. 4

When Revascularization is NOT Indicated

• Revascularization is not recommended if the reason is solely to prevent progression to CLTI in patients with asymptomatic PAD. 1
• Primary amputation should be evaluated for patients with significant necrosis of weight-bearing portions of the foot (in ambulatory patients), uncorrectable flexion contracture, paresis of the extremity, refractory ischemic rest pain, sepsis, or very limited life expectancy. 1
• Revascularization is not recommended in limbs with limited life expectancy where procedural risk outweighs benefit. 4

Critical Pitfalls to Avoid

• Never delay revascularization—every hour increases amputation risk. 4
• Do not perform revascularization solely based on low ABI (<0.4) without clinical symptoms of CLTI. 1
• Do not withhold revascularization attempts based solely on anatomic complexity—unconventional techniques for complex below-the-knee disease may be successful. 5
• Do not overlook the interdisciplinary team approach—wound care, infection control, and cardiovascular risk factor management are equally critical to revascularization success. 1, 4