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critical limb ischemia

Etiology: 1) atherosclerosis 2) acute arterial occlusion Pathology: - arterial thrombosis or arterial embolization may be superimposed on progression of severe atherosclerosis (see acute arterial occlusion) Clinical manifestations: 1) pulseless 2) painful -> paresthesia -> complete sensory loss with necrosis 3) pallor 4) paralysis 5) poikilothermy Radiology: - arteriography (angiography) a) anticoagulation with heparin prior to arteriography b) identify the site & nature of rterial occlusion Complications: - tissue necrosis - compartment syndrome from tissue swelling after reperfusion [1] Management: 1) severe claudication but no pain at rest a) anticoagulation with heparin & b) antiplatelet therapy 2) revascularization in a threatened, but viable limb [1,2] a) angioplasty or embolectomy catheter b) intra-arterial thrombolytic therapy 1] urokinase or tPA better than streptokinase 2] 82% salvage rate at 1 year 3) surgical reconstruction (bypass) when angioplasty/embolectomy & thrombolysis are not feasible or ineffective - incidence of a major adverse limb event or death is significantly lower with bypass than endovascular angioplasty or embolectomy [8] 4) below-the-ankle interventions are feasible & provide good clinical outcome [7] 5) careful monitoring after reperfusion - frequent reocclusion, limb edema, compartment syndrome 6) amputation if limb not viable [1,2] a) anesthesia, paralysis, absent doppler, muscle rigor b) blacks more likely than hispanics or whites to undergo limb amputation [3]

Specific

acute peripheral arterial occlusion (severe acute limb ischemia) chronic limb-threatening ischemia

General

peripheral arterial disease; peripheral artery atherosclerosis (PAD) ischemia

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2022.
  2. BASIL Trial Participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): Multicentre, randomised controlled trial. Lancet 2005; 366:1925 PMID: 16325694 - Goy JJ & Urban P Life and limb: Bypass versus angioplasty in the ischaemic limb. Lancet 2005; 366:1905 PMID: 16325681
  3. Durazzo TS et al Influence of Race on the Management of Lower Extremity Ischemia. Revascularization vs Amputation. JAMA Surg. 2013;():1-6. March 20, 2013 PMID: 23552850 http://archsurg.jamanetwork.com/article.aspx?articleid=1669979
  4. Feiring AJ, Krahn M, Nelson L et al Preventing leg amputations in critical limb ischemia with below-the-knee drug-eluting stents: the PaRADISE (PReventing Amputations using Drug eluting StEnts) trial. J Am Coll Cardiol. 2010 Apr 13;55(15):1580-9. PMID: 20378075
  5. Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med. 2012 Jun 7;366(23):2198-206. PMID: 22670905
  6. Lou N. Revascularization Feasible for Below-The-Ankle CLI Limbs salvaged in most severe cases per single-center study MedPage Today. March 20, 2018 https://www.medpagetoday.com/meetingcoverage/sir/71890 - Arslan B, et al Midterm outcomes after below the ankle interventions for Rutherford 5-6 critical limb ischemia patients. Society of Interventional Radiology (SIR) 2018.
  7. Misra S, Shishehbor MH, Takahashi EA, et al AHA SCIENTIFIC STATEMENT. Perfusion Assessment in Critical Limb Ischemia: Principles for Understanding and the Development of Evidence and Evaluation of Devices. A Scientific Statement From the American Heart Association. Circulation. Aug 2019 PMID: 31401843 https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000708
  8. Farber A, Menard MT, Conte MS et al Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia. N Engl J Med. 2022. Nov 7. PMID: 36342173 https://www.nejm.org/doi/full/10.1056/NEJMoa2207899