Interventional management of critical limb ischemia in renal patients

Critical limb ischemia (CLI) represents the most severe clinical manifestation of peripheral arterial disease (PAD), defined as the presence of chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease. The occurrence of CLI in patients with kidney insufficiency portends a strikingly high rate of subsequent morbidity and mortality. Generally, the primary therapy for CLI is revascularization of the affected limb. However, patients with CLI and kidney insufficiency represent a unique and challenging patient subset, and data from surgical series suggest reduced rates of limb salvage and higher medium and long-term mortality rates for patients with kidney insufficiency compared with those with normal kidney function. In contemporary practice, endovascular techniques are fast replacing surgical bypass as the first-line revascularization strategy for CLI, based on high technical success rates and low rates of procedure-related morbidity and mortality. However, a large series on endovascular outcomes for the treatment of CLI in patients with kidney insufficiency is lacking. Based on the severely reduced long-term survival rates of patients with CLI and kidney insufficiency, future efforts should focus on early detection of PAD in patients with kidney insufficiency and institution of aggressive medical therapy to prevent progression in the global burden of atherosclerosis in this patient population.