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Published on: September 22, 2020
Open surgery for chronic limb ischemia: a review
J B Ricco1, L Thanh Phong, R Belmonte
1Vascular Surgery Department, Jean Bernard Hospital University of Poitiers, Poitiers, France - jeanbaptistericco@gmail.com.
Insights
Revascularization strategies for chronic limb ischemia (CLI) lack strong evidence. Best treatment depends on disease extent, patient fitness, and vein availability, often requiring multidisciplinary care.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Clinical Evidence Synthesis
Background:
- Chronic limb ischemia (CLI) presents complex revascularization challenges.
- Clinical evidence guiding therapeutic decisions in CLI is limited.
- Optimal management requires careful consideration of individual patient factors.
Purpose of the Study:
- To review current revascularization strategies for chronic limb ischemia.
- To provide evidence-based recommendations for managing CLI.
- To emphasize the need for a multidisciplinary approach in CLI care.
Main Methods:
- Systematic review of revascularization techniques for CLI.
- Analysis of clinical evidence for different surgical and endovascular approaches.
- Evaluation of graft options, including autologous veins and prosthetic grafts.
Main Results:
- Aortobifemoral bypass is preferred for diffuse aortoiliac disease in surgical candidates.
- Primary stenting is recommended for unilateral iliac occlusion; bypass for extensive iliofemoral disease.
- Saphenous vein bypass is optimal for infrainguinal disease with long occlusions or multiple infrapopliteal lesions.
- Endovascular techniques suit short lesions and limited life expectancy.
- Amputation is sometimes the best option for select CLI patients.
Conclusions:
- Neither an "endo-first" nor a "bypass-first" approach is universally appropriate for CLI.
- CLI management necessitates individualized treatment strategies.
- Specialized, multidisciplinary care is crucial for limb and life preservation in CLI patients.
Abstract:
This review considers the role of the different revascularization strategies in patients with chronic limb ischemia (CLI) and reveals that clinical evidence guiding therapeutic decision-making in CLI is poor and only careful basic recommendations can be made. For diffuse aortoiliac disease with occlusion of the aorta, aortobifemoral bypass remains the best option if the patient is fit for open surgery. Unilateral iliac occlusion should be treated by primary stenting, but an iliofemoral bypass may be the best option when the disease extends down to the common and deep femoral arteries. For infrainguinal revascularisation, bypass using the saphenous vein remains the best option for patients with occlusion of the superficial femoral artery >25 cm and for patients with multiple occlusions of the infrapopliteal arteries. In the absence of leg veins, arm veins should be used. Prosthetic grafts are the last option. Endovascular techniques are recommended in patients with short arterial lesions and limited life expectancy <2 years. Finally some patients with CLI are best treated by primary amputation. In conclusion, this review demonstrates that neither an endo- first nor a bypass-first attitude is appropriate in patients with CLI and suggests that these patients should be cared for by specialists in a multidisciplinary center in order to preserve their life and limbs, to conduct clinical trials and to control costs.
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