CC BY-NC-ND 4.0 · Indian J Radiol Imaging 2019; 29(03): 258-263
DOI: 10.4103/ijri.IJRI_208_19
Interventional Radiology

Current review with evolving management strategies in critical limb ischemia

Arun Sharma
Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
› Author Affiliations
Financial support and sponsorship Nil.

Abstract

Critical limb ischemia represents the end stage of peripheral artery disease, which is associated with impaired quality of life and considerable morbidity and mortality. Economical impact of the disease is huge with a substantial burden on patients, healthcare providers, and resources. Varied therapeutic strategies have been employed in the management of these patients. These patients usually have complex multilevel occlusive arteriopathy with significant comorbidities, rendering surgical interventions undesirable in many cases. Recent therapeutic advances with evolving endovascular techniques and gene or cell-based therapies have the potential to dramatically change the therapeutic outlook in these patients.



Publication History

Received: 06 May 2019

Accepted: 25 June 2019

Article published online:
22 July 2021

© 2019. Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India

 
  • References

  • 1 Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. TASC II Working Group. TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2007; 45 Suppl S S5-67
  • 2 Conte MS. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) and the (hoped for) dawn of evidence-based treatment for advanced limb ischemia. J Vasc Surg 2010; 51 (05) Suppl 69S-75S
  • 3 Farber A, Eberhardt RT. The current state of critical limb ischemia: A systematic review. JAMA Surg 2016; 151: 1070-7
  • 4 Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S. et al. Recommended standards for reports dealing with lower extremity ischemia: Revised version. J Vasc Surg 1997; 26: 517-38
  • 5 Patel MR, Conte MS, Cutlip DE, Dib N, Geraghty P, Gray W. et al. Evaluation and treatment of patients with lower extremity peripheral artery disease: Consensus definitions from Peripheral Academic Research Consortium (PARC). J Am Coll Cardiol 2015; 65: 931-41
  • 6 Mills Sr JL, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN. et al. Society for Vascular Surgery Lower Extremity Guidelines Committee. The Society for Vascular Surgery lower extremity threatened limb classification system: Risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg 2014; 59: 220-34.e1-2
  • 7 Zhan LX, Branco BC, Armstrong DG, Mills Sr JL. The Society for Vascular Surgery lower extremity threatened limb classification system based on wound, ischemia, and foot infection (WIfI) correlates with risk of major amputation and time to wound healing. J Vasc Surg 2015; 61: 939-44
  • 8 Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM. et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: A systematic review and analysis. Lancet 2013; 382: 1329-40
  • 9 Criqui MH, Langer RD, Fronek A, Feigelson HS, Klauber MR, McCann TJ. et al. Mortality over a period of 10 years in patients with peripheral arterial-disease. N Engl J Med 1992; 326: 381-6
  • 10 Shammas NW. Epidemiology, classification, and modifiable risk factors of peripheral arterial disease. Vasc Health Risk Manag 2007; 3: 229-34
  • 11 Management of peripheral arterial disease (PAD). TransAtlantic Inter-Society Consensus (TASC). Eur J Vasc Endovasc Surg 2000; 19 (Suppl A):Si-xxviii S1-250
  • 12 Biancari F. Meta-analysis of the prevalence, incidence and natural history of critical limb ischemia. J Cardiovasc Surg (Torino) 2013; 54: 663-9
  • 13 Nehler MR, Duval S, Diao L, Annex BH, Hiatt WR, Rogers K. et al. Epidemiology of peripheral arterial disease and critical limb ischemia in an insured national population. J Vasc Surg 2014; 60: 686-95
  • 14 Nehler MR, Peyton BD. Is revascularization and limb salvage always the treatment for critical limb ischemia?. J Cardiovasc Surg 2004; 45: 177-84
  • 15 Watelet J, Soury P, Menard JF, Plissonnier D, Peillon C, Lestrat JP. et al. Femoropopliteal bypass: In situ or reversed vein grafts? Ten-year results of a randomized prospective study. Ann Vasc Surg 1997; 11: 510-9
  • 16 Conte MS, Bandyk DF, Clowes AW, Moneta GL, Seely L, Lorenz TJ. et al. Results of PREVENT III: A multicenter, randomized trial of edifoligide for the prevention of vein graft failure in lower extremity bypass surgery. J Vasc Surg 2006; 43: 742-50
  • 17 Bertelè V, Roncaglioni MC, Pangrazzi J, Terzian E, Tognoni EG. Clinical outcome and its predictors in 1560 patients with critical leg ischaemia. Eur J Vasc Endovasc Surg 1999; 18: 401-10
  • 18 Varu VN, Hogg ME, Kibbe MR. Critical limb ischemia. J Vasc Surg 2010; 51: 230-41
  • 19 Goodney PP, Likosky DS, Cronenwett JL. Predicting ambulation status one year after lower extremity bypass. J Vasc Surg 2009; 49: 1431-9
  • 20 Hertzer NR, Beven EG, Young JR, O’Hara PJ, Ruschhaupt 3rd WF, Graor RA. et al. Coronary artery disease in peripheral vascular patients: A classification of 1000 coronary angiograms and results of surgical management. Ann Surg 1984; 199: 223-33
  • 21 Cheng SW, Wu LL, Ting AC, Lau H, Wong J. Screening for asymptomatic carotid stenosis in patients with peripheral vascular disease: A prospective study and risk factor analysis. Cardiovasc Surg 1999; 7: 303-9
  • 22 Varty K, Nydahl S, Nasim A, Bolia A, Bell PR, London JM. Results of surgery and angioplasty for the treatment of chronic severe lower limb ischaemia. Eur J Vasc Endovasc Surg 1998; 16: 159-63
  • 23 Dorros G, Jaff MR, Dorros AM, Mathiak LM, He T. Tibioperoneal (outflow lesion) angioplasty can be used as primary treatment in 235 patients with critical limb ischemia: Five-year follow-up. Circulation 2001; 104: 2057-62
  • 24 Coats P, Wadsworth R. Marriage of resistance and conduit arteries breeds critical limb ischemia. Am J Physiol Heart Circ Physiol 2005; 288: H1044-50
  • 25 Vogt MT, McKenna M, Wolfson SK, Kuller LH. The relationship between ankle brachial index, other atherosclerotic disease, diabetes, smoking and mortality in older men and women. Atherosclerosis 1993; 101: 191-202
  • 26 Williams DT, Harding KG, Price P. An evaluation of the efficacy of methods used in screening for lower-limb arterial disease in diabetes. Diabetes Care 2005; 28: 2206-10
  • 27 Cao P, Eckstein HH, De Rango P, Setacci C, Ricco JB, de Donato G. et al. Chapter II: Diagnostic methods. Eur J Vasc Endovasc Surg 2011; 42 (02) S13-32
  • 28 Conte MS, Bandyk DF, Clowes AW, Moneta GL, Namini H, Seely L. Risk factors, medical therapies and perioperative events in limb salvage surgery: Observations from the PREVENT III multicenter trial. J Vasc Surg 2005; 42: 456-64
  • 29 Raghunathan A, Rapp JH, Littooy F, Santilli S, Krupski WC, Ward HB. et al. Postoperative outcomes for patients undergoing elective revascularization for critical limb ischemia and intermittent claudication: A subanalysis of the Coronary Artery Revascularization Prophylaxis (CARP) trial. J Vasc Surg 2006; 43: 1175-82
  • 30 Armstrong EJ, Wu J, Singh GD, Dawson DL, Pevec WC, Amsterdam EA. et al. Smoking cessation is associated with decreased mortality and improved amputation-free survival among patients with symptomatic peripheral artery disease. J Vasc Surg 2014; 60: 1565-71
  • 31 Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000; 342: 145-53
  • 32 Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK. et al. Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society for Vascular Medicine; Society for Vascular Surgery. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 58: 2020-45
  • 33 Bhatt DL, Fox KA, Hacke W, Berger PB, Black HR, Boden WE. et al. CHARISMA Investigators. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 2006; 354: 1706-17
  • 34 Smith FB, Bradbury A, Fowkes G. Intravenous naftidrofuryl for critical limb ischaemia. Cochrane Database of Syst Rev 2012; CD002070 DOI: 10.1002/14651858.
  • 35 Miyashita Y, Saito S, Miyamoto A, Iida O, Nanto S. Cilostazol increases skin perfusion pressure in severely ischemic limbs. Angiology 2011; 62: 15-7
  • 36 Giles KA, Pomposelli FB, Spence TL, Hamdan AD, Blattman SB, Panossian H. et al. Infrapopliteal angioplasty for critical limb ischemia: Relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs. J Vasc Surg 2008; 48: 128-36
  • 37 Stoner MC, Defreitas DJ, Manwaring MM, Carter JJ, Parker FM, Powell CS. Cost per day of patency: Understanding the impact of patency and reintervention in a sustainable model of healthcare. J Vasc Surg 2008; 48: 1489-96
  • 38 Forbes JF, Adam DJ, Bell J, Fowkes FG, Gillespie I, Raab GM. et al. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Health-related quality of life outcomes, resource utilization, and cost-effectiveness analysis. J Vasc Surg 2010; 51: 43S-51S
  • 39 Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF. et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): Multicentre, randomised controlled trial. Lancet 2005; 366: 1925-34
  • 40 Dake MD, Ansel GM, Jaff MR, Ohki T, Saxon RR, Smouse HB. et al. Paclitaxel-eluting stents show superiority to balloon angioplasty and bare metal stents in femoropopliteal disease: Twelve-month Zilver PTX randomized study results. Circ Cardiovasc Interv 2011; 4: 495-504
  • 41 Dake MD, Ansel GM, Jaff MR, Ohki T, Saxon RR, Smouse HB. et al. Sustained safety and effectiveness of paclitaxel-eluting stents for femoropopliteal lesions: 2-year follow-up from the Zilver PTX randomized and single-arm clinical studies. J Am Coll Cardiol 2013; 61: 2417-27
  • 42 Fusaro M, Cassese S, Ndrepepa G, Tepe G, King L, Ott I. et al. Drug-eluting stents for revascularization of infrapopliteal arteries: Updated meta-analysis of randomized trials. JACC Cardiovasc Interv 2013; 6: 1284-93
  • 43 Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi JR, Skillman JJ. et al. Major lower extremity amputation: Outcome of a modern series. Arch Surg 2004; 139: 395-9
  • 44 Stone PA, Flaherty SK, Aburahma AF, Hass SM, Jackson JM, Hayes JD. et al. Factors affecting perioperative mortality and wound-related complications following major lower extremity amputations. Ann Vasc Surg 2006; 20: 209-16
  • 45 Ko SH, Bandyk DF. Therapeutic angiogenesis for critical limb ischemia. Semin Vasc Surg 2014; 27: 23-31
  • 46 Belch J, Hiatt WR, Baumgartner I, Driver IV, Nikol S, Norgren L. et al. Effect of fibroblast growth factor NV1FGF on amputation and death: A randomised placebo-controlled trial of gene therapy in critical limb ischaemia. Lancet 2011; 377: 1929-37
  • 47 Powell RJ, Simons M, Mendelsohn FO, Daniel G, Henry TD, Koga M. et al. Results of a double-blind, placebo-controlled study to assess the safety of intramuscular injection of hepatocyte growth factor plasmid to improve limb perfusion in patients with critical limb ischemia. Circulation 2008; 118: 58-65
  • 48 Teraa M, Sprengers RW, van der Graaf Y, Peters CE, Moll FL, Verhaar MC. Autologous bone marrow-derived cell therapy in patients with critical limb ischemia: A meta-analysis of randomized controlled clinical trials. Ann Surg 2013; 258: 922-9
  • 49 Peeters Weem SM, Teraa M, de Borst GJ, Verhaar MC, Moll FL. Bone marrow derived cell therapy in critical limb ischemia: A meta-analysis of randomized placebo controlled trials. Eur J Vasc Endovasc Surg 2015; 50: 775-83
  • 50 Osipova O, Saaya S, Karpenko A, Zakian S, Aboian E. Cell therapy of critical limb ischemia-problems and prospects. Vasa 2019; 10: 1-11
  • 51 Vicenti G, Bizzoca D, Caruso I, Nappi VS, Giancaspro G, Carrozzo M. et al. New insights into the treatment of non-healing diabetic foot ulcers. J Biol Regul Homeost Agents 2018; 32 (06) 15-21
  • 52 Kontopodis N, Tavlas E, Papadopoulos G, Pantidis D, Kafetzakis A, Chalkiadakis G. et al. Effectiveness of Platelet-Rich Plasma to Enhance Healing of Diabetic Foot Ulcers in Patients With Concomitant Peripheral Arterial Disease and Critical Limb Ischemia. Int J Low Extrem Wounds 2016; 15: 45-51
  • 53 Del Giudice C, Van Den Heuvel D, Wille J, Mirault T, Messas E, Ferraresi R. et al. Percutaneous deep venous arterialization for severe critical limb ischemia in patients with no option of revascularization: Early experience from two european centers. Cardiovasc Intervent Radiol 2018; 41: 1474-80
  • 54 Kum S, Huizing E, Schreve MA, Ünlü Ç, Ferraresi R, Samarakoon LB. et al. Percutaneous deep venous arterialization in patients with critical limb ischemia. J Cardiovasc Surg (Torino) 2018; 59: 665-9