Critical limb ischemia and its treatments: a review

Critical limb ischemia (CLI) encompasses the most extreme end of the peripheral artery disease (PAD) spectrum leading to significant morbidity and mortality. CLI is defined as greater than 2 weeks of extremity rest pain, ulcers or extremity gangrene, secondary to objectively proven peripheral artery disease. Corresponding to Fontaine Stages III/IV and Rutherford category IV through VI, CLI is a complex disease comprising of both macrovascular and microvascular systems with inconsistent historical data on optimal treatment. CLI is distinct from intermittent claudication with different goals of treatment, however in both groups risk factor modification is of the utmost importance involving tobacco cessation, and treatment of underlying conditions like diabetes mellitus, hyperlipidemia and hypertension. In CLI, medical therapy involves wound care and also consists of antiplatelet therapy, anti-inflammatory therapy including statin use or ACE inhibitors. Surgical therapies include distal bypass surgery, thromboendartectomy and amputation. Endovascular techniques include percutaneous transluminal angioplasty, bare metal stents, atherectomy, drug-coated balloon and drug-eluting stents. CLI is considered the end-stage of PAD, requiring a thoughtful and multidisciplinary approach, risk-benefit analysis and treatment of comorbid conditions. Conservative and surgical treatments, along with endovascular techniques, have allowed excellent opportunities for treating complicated patients for wound healing and limb salvage.