Management of Non-Reconstructable Critical Limb Ischemia

At least 15% of patients with critical limb ischemia are not candidates for standard revascularization. In this day and age, with new techniques-including retrograde access to the foot-and numerous angioplasty and atherectomy techniques available, the critical limb ischemia patient can still be faced without options. Distal bypass surgery may still remain the gold standard, and likely permits the patient to have the best options for healing, but carries significant comorbidities after undergoing the procedure. There are patients who do not have targets of interest in their foot for arterial revascularization and there are patients who have very poor conduit or are very poor candidates due to their medical comorbidities. Guidelines as to who should and should not undergo surgery-or even percutaneous revascularization-are starting to become more widely accepted. We are starting to see the tide change and there is interest in this cohort of patients. There are patients with no distal target that may benefit from an arteriovenous bypass, which is regaining popularity and can be done completely endovascularly. The patient that may be a very poor candidate for intervention may benefit from arterial counterpulsation therapy and/or topical oxygen therapy (which are commercially available). They may also benefit from placental stem cell injection, which is undergoing Phase II trial assessment. We will review the current literature as it surrounds these potential therapeutic interventions for patients with significant lower extremity ischemia who do not have standard revascularization options.