Peripheral arterial disease (PAD) affects about 8 million people in the United States. Critical limb ischemia (CLI) is the most advanced form of this disease and occurs in 1% to 2% of patients who are 50 years of age or older.
Risk is usually associated with lifestyle factors, such as smoking, obesity and physical inactivity, or chronic diseases like diabetes, hypertension or hyperlipidemia. PAD patients typically face an increased risk for heart attack, stroke and lower extremity amputation. Limb-threatening ischemia occurs in 1% to 2% of patients who are 50 years of age or older.
CLI is usually characterized by persistent, recurring rest pain requiring regular analgesia. This condition may also reveal non-healing ulcerations or gangrene of the leg, ankle, foot or toes. The ulcers are often extremely painful, even for patients who have decreased sensation due to neuropathy. In these cases, threatened limb or tissue loss is likely.
When a patient presents with symptoms indicating severe PAD or CLI, a referral to a limb salvage specialist is strongly recommended. Symptoms such as rest pain upon elevation of a lower extremity, intermittent claudication, or non-healing foot or leg ulcers are suggestive of moderate to advanced PAD and warrant further investigation. In cases where these symptoms are accompanied by a history of diabetes, smoking, or both, an immediate referral is strongly recommended. In addition, when PAD is suspected in the presence of a non-healing ulcer, a consult with a vascular specialist is essential to avoid a catastrophic event, such as a heart attack, stroke or limb amputation.
6 P’s of Acute
Note: The evolution to paresthesia and paralysis usually reflects the presence of severe and potentially irreversible ischemia.
Minimally invasive endovascular therapy can be a successful treatment option depending on the location and severity of the blockages. Most patients with CLI have multiple arterial blockages, including blockages of the arteries below the knee, and frequently, chronic total occlusions (CTOs) of vessels. In general, puncture of the groin, under local anesthesia, with insertion of a catheter into the artery in the groin will allow access to the diseased portion of the artery.
Some of the endovascular procedures used to treat CLI include balloon angioplasty, stents and devices to open completely blocked arteries such as the Crosser catheter. This device employs a high frequency oscillating wire tip combined with a water jet to cross CTOs in arteries. A second device, the Stealth orbital atherectomy catheter, is often employed with the Crosser catheter. In this device, an eccentrically positioned burr on a catheter selectively sands down the calcium inside the diseased artery, increasing the flexibility of the vessel and widening the channel for blood to flow.
Treatment of CLI is also coordinated with the patient’s primary care physician to optimize management of diabetes and to detect and treat carotid vascular disease, coronary artery disease and known risk factors for stroke and heart attack. There are no drugs currently approved by the U.S. Food and Drug Administration for the treatment of CLI.
The bottom line is that time is truly of the essence when treating patients with symptomatic PAD. Consulting with a limb salvage specialist will help reduce the risk inherent in managing these medically complicated patients.
Lawrence Schmetterer, MD, FACS, is a cardiovascular and thoracic surgeon and Chief of the Department of Surgery at Salem Community Hospital (SCH). His office is located at 20 Ohltown Road, Suite 206, in Austintown, OH. He also provides a cardiovascular clinic at SCH.