Critical limb Ischemia (CLI) is the most severe form of peripheral arterial disease (PAD). Patients with severe leg pain due to poor blood flow are said to have critical limb ischemia (CLI). Ischemia means “insufficient blood flow.” Critical limb ischemia can severely affect a patient’s quality of life. Also, patients with CLI are more likely to die of heart attacks and other problems related to vascular disease like stroke.

Critical limb ischemia is the end result of arterial occlusive disease, most commonly atherosclerosis. In addition to atherosclerosis in association with hypertension, hypercholesterolemia, cigarette smoking and diabetes, less frequent causes of chronic critical limb ischemia include Buerger’s disease, or thromboangiitis obliterans, and some forms of arteritis.

Diabetes is a particularly important risk factor because it is frequently associated with severe peripheral arterial disease. Atherosclerosis develops at a younger age in patients with diabetes and progresses rapidly. Moreover, atherosclerosis affects more distal vessels in patients with diabetes; the profunda femoris, popliteal and tibial arteries are frequently affected, while the aorta and iliac arteries are minimally narrowed. These distal lesions are less amenable to revascularization. Atherosclerosis in distal arteries in combination with diabetic neuropathy contributes to the higher rates of limb loss in diabetic patients compared with nondiabetic patients.

So the key risk factors of CLI as follows;

Age

Smoking

Diabetes

Overweight or obesity

Sedentary lifestyle

High cholesterol

High blood pressure

Family history of atherosclerosis or claudication

CLI more likely to be found in patients with a history of cramping in the calves that occurs when walking but stops when you rest. It is also found smokers, diabetics, or people with a history of stroke.

The most prominent features of critical limb ischemia (CLI) are called ischemic rest pain — severe pain in the legs and feet while a person is not moving, or non-healing sores on the feet or legs.

Pain or numbness in the feet

Shiny, smooth, dry skin of the legs or feet

Thickening of the toenails

Absent or diminished pulse in the legs or feet

Open sores, skin infections or ulcers that will not heal

Dry gangrene (dry, black skin) of the legs or feet

Auscultation: The presence of a bruit, or “whooshing” sound, in the arteries of the legs is confirmed using a stethoscope .

Ankle-brachial index (ABI): The systolic blood pressure in the arm is divided by the systolic pressure at the ankle. Ankle systolic pressure of 50 mm Hg or less or a toe systolic pressure of 30 mm Hg or less suggests the presence of critical limb ischemia. Patients with claudication typically have an ankle-brachial index of 0.5 to 0.8, while patients with critical limb ischemia usually have an ankle-brachial index of 0.4 or less.

Doppler Ultrasound: This form of ultrasound can measure the direction and velocity of blood-flow through the vessels.

CT angiography: An advanced X-ray procedure that uses a computer to generate three-dimensional images.

Magnetic resonance angiography (MR angiography): The patient is exposed to radiofrequency waves in a strong magnetic field. The energy that is released is measured by a computer and used to construct two- and three-dimensional images of the blood vessels.

Angiogram: An X-ray study of the blood vessels is taken using contrast dyes.

Critical limb ischemia is a serious condition that requires immediate treatment to re-establish blood-flow to the affected area. The number one priority is to preserve the limb.

Minimally invasive endovascular therapy is often an option in the care of CLI. The Vascular Center has the full complement of endovascular treatments available. The treatment recommended depends on the location and severity of the blockages. Most patients with CLI have multiple arterial blockages, including blockages of the arteries below the knee. 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:

Angioplasty: A tiny balloon is inserted through a puncture in the groin. The balloon is inflated one or more times, using a saline solution, to open the artery.

Cutting balloon: A balloon imbedded with micro-blades is used to dilate the diseased area. The blades cut the surface of the plaque, reducing the force necessary to dilate the vessel.

Cold balloon (CryoPlasty): Instead of using saline, the balloon is inflated using nitrous oxide. The gas freezes the plaque. The procedure is easier on the artery; the growth of the plaque is halted; and little scar tissue is generated.
Stents: Metal mesh tubes that provide scaffolding are left in place after an artery has been opened using a balloon angioplasty.

Balloon-expanded: A balloon is use to expand the stent. These stents are stronger but less flexible.

Self-expanding: Compressed stents are delivered to the diseased site. They expand upon release. These stents are more flexible.

Laser atherectomy: Small bits of plaque are vaporized by the tip of a laser probe.

Directional atherectomy: A catheter with a rotating cutting blade is use to physically remove plaque from the artery, opening the flow channel.
Recovery from these procedures usually takes one or two days, and most of these procedures are done on an outpatient basis. Treatment includes management of the risk factors of atherosclerosis.

Treatment of wounds or ulcers may require additional surgical procedures or other follow-up care. If the arterial blockages are not favorable for endovascular therapy, surgical treatment is often recommended. This typically involves bypass around the diseased segment with either a vein from the patient or a synthetic graft. Hospitalization after a bypass operation varies from a few days to more than a week. Recovery from surgery may take several weeks.

 

Critical limb ischemia is characterized with intolerable pain at rest and nonhealing wounds and/or gangrene. The treatment of nonhealing wounds in patients with critical limb ischemia calls for an extraordinary effort. However, major amputation is required in a significant number of patients. Hyperbaric oxygen therapy is one of the adjunctive treatments used in nonhealing wounds. Hyperbaric oxygen therapy enhances collagen synthesis and maturation, fibroblast proliferation, epithelialization, increases leukocyte bacterial-killing capacity and induces angiogenesis. Hyperbaric oxygen therapy also exerts an antibacterial effect on selected microorganisms and reduces wound infection. Hyperbaric oxygen therapy is not a miraculous treatment modality. It is a good adjunctive therapy that increases the healing rate of wounds in selected patients. Hyperbaric oxygen therapy should be instituted together with conventional treatments. Antibiotherapy, strict metabolic control, daily wound care and debridement should not be overlooked during hyperbaric oxygen therapy.

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CLI Treatment

Counseling
Diagnostic and assessment
Diet Counseling
Pharmacological Intervention
Angioplasty
Stents
Laser Atherectomy
Wounds Healing
Hyperbaric Oxygen Therapy
SCT Regenerative Medical Intervention (Experimental) & Clinical case studies