Endovascular therapy for critical limb ischemia

Abstract

Critical limb ischemia (CLI) represents an advanced disease state of peripheral arterial disease. It manifests as lower extremity ischemic rest pain or ischemic skin lesions leading to ulceration or gangrene. Patients with CLI often have multiple medical comorbidities and a 1-year mortality rate of 25% and a 1-year amputation rate of 25%. Historically, bypass surgery with autogenous veins for flow restoration has been the first-line therapy for CLI. However, advances in endovascular techniques and device technology have changed the treatment paradigm. Catheter-based technologies are rapidly evolving at a rate that is outpacing large-scale studies evaluating relevant clinical outcomes. Patients with CLI require a multidisciplinary management approach centered on aggressive medical therapies, wound care and prompt revascularization, with an emphasis on limb salvage. This review summarizes the contemporary endovascular therapies including balloon angioplasty, atherectomy and bare-metal stenting. In addition, we review emerging technologies, such as drug-eluting stents, drug-coated balloons and chronic total occlusion recanalization devices.

Keywords:

• angioplasty
• atherectomy
• chronic total occlusion
• critical limb ischemia
• endovascular
• limb salvage
• peripheral arterial disease
• revascularization
• stent

Financial & competing interests disclosure

Dr. Mahmud reports receiving research grant support from Corindus, serves as a consultant for Abbott Vascular and serves on the speakers bureau for Medtronic. Dr. Patel serves on the speakers bureau for Astra Zeneca. The remaining authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Critical limb ischemia represents an advanced presentation of peripheral arterial disease and manifests as lower extremity ischemic rest pain or ischemic skin lesions leading to ulceration or gangrene.

• 1-year mortality rates reach 25% for patients with CLI and 1-year major amputation rates are also 25%.

• Advances in percutaneous interventional revascularization techniques and technology have transitioned the treatment paradigm from a predominantly surgical approach to a percutaneous approach.

• There has been an overall decline in amputation rates in the past decade, likely due to a combination of earlier detection, prompt referral, improved medical and wound care management, and advances in endovascular interventions.

• Preventing major amputation remains the principal treatment goal in any CLI revascularization procedure.

• Current clinical trials and registry data encompassing the various revascularization techniques and multitude of adjunctive tools and technology are limited by low numbers of patients with CLI in comparison with claudicants.

• A comprehensive team of providers including the primary physician, podiatrist, wound care specialist and vascular specialist best provides the optimal management of the patient with CLI.