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chronic limb-threatening ischemia

Etiology: - see critical limb ischemia Pathology: - see critical limb ischemia Clinical manifestations: - > 2 weeks of ischemic pain at rest - non-healing arterial ulcers or wounds - gangrene attributable to peripheral arterial disease - inability to exercise due to arterial ulcers &/or ischemic pain at rest - pulseless, pallor, paralysis, poikilothermy (cool extremity) Special laboratory: - ankle/brachial index often < 0.4 - arteriography allows for endovascular revascularization a) anticoagulation with heparin prior to arteriography b) identify the site & nature of arterial occlusion Radiology: - CT angiography allegedly results in clinically significant treatment delays [1] Complications: - tissue necrosis - compartment syndrome from tissue swelling after reperfusion [1] Management: - referral for revascularization is indicated in patients with rest pain, ulceration, or gangrene [1] - endovascular revascularization generally preferred [1] - minimally invasive - lower risk for perioperative adverse events vs surgical revascularization - surgical revascularization recommended for long chronic total occlusions, multisegment disease [1] - transcatheter arterialization of deep veins may benefit patients not amenable to treatable with conconventional arterial revascularization - also see critical limb ischemia

General

critical limb ischemia

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 19 American College of Physicians, Philadelphia 2022 - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  2. Farber A Chronic Limb-Threatening Ischemia N Engl J Med. 2018 Jul 12;379(2):171-180 PMID: 29996085 https://www.nejm.org/doi/10.1056/NEJMcp1709326
  3. Shishehbor MH et al. Transcatheter arterialization of deep veins in chronic limb-threatening ischemia. N Engl J Med 2023 Mar 30; 388:1171. PMID: 36988592 https://www.nejm.org/doi/10.1056/NEJMoa2212754