[Prevention is the name of the game]

The review on critical limb ischemia (CLI) by Melamed and his co-authors in this issue of Harefuah focuses on treatment modalities but does not address the important issue of prevention, which, I believe, is the most effective tool in saving limbs. Peripheral arterial occlusion secondary to atherosclerosis (ASO) is common in the western hemisphere. Ten percent of the population between the ages 50-55 years and more than 20% of the population over 70 years of age suffer from some degree of ASO. Three percent of these patients will develop severe forms of ischemia. The problem is even worse amongst diabetic patients, where 1 in 1000 will lose a leg. Most patients with leg pain are treated by the orthopedic surgeon and many of those with minor skin changes are referred to a dermatologist, often without proper vascular evaluation, until the condition deteriorates. The secret of limb preservation is threefold: 1) High level of awareness by the primary medical team 2) Dedicated foot clinics and 3) A multidisciplinary team. A rigid protocol of foot examination, pulse palpation and Doppler evaluation, combined with clinical education regarding proper foot wear, can prevent close to 70% of major limb amputations. These simple, inexpensive and non-invasive modalities enable us to both diagnose arterial disease and follow-up on the treatment. An interdisciplinary team of a diabetes expert, foot orthopedic surgeon, podiatrist and a vascular surgeon can, in most cases, build a treatment plan which will alter the course of the disease at an early stage and prevent the development of CLI. The natural course of CLI without revascularization leads to major limb amputation in 70% of patients within a year or two of diagnosis. When vascular reconstruction is not an option, more conservative measures, such as hyperbaric oxygen therapy (HBO), can also be useful in some patients but over-use and abuse of this modality and other alternative treatments must be avoided. The fact that 30% of those patients do not lose their leg, leads to unsubstantiated claims of limb salvage by unproven methods. A major effort of educating both the medical teams and the patients is required in order to decrease the number of patients who will develop CLI. On the other hand, one must remember that for some patients primary amputation can be the best alternative, offering minimal risk and a reasonable quality of life.