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Revascularisation Options for Chronic Limb Threatening Ischaemia in Diabetes: Implications From Two Recent Trials

Jaime H X Lin1,2, Nikolaos Papanas3, Hany Zayed4

  • 1Diabetes and Diabetic Foot, King's College NHS Foundation Trust, London, UK.

The International Journal of Lower Extremity Wounds
|July 19, 2023
PubMed

Insights

For chronic limb-threatening ischaemia (CLTI), recent trials suggest an individualized revascularization strategy is best. Optimal management requires a multidisciplinary approach for patients with diabetes and CLTI.

Area of Science:

  • Vascular Surgery
  • Cardiovascular Medicine
  • Diabetic Foot Care

Background:

  • Chronic limb-threatening ischaemia (CLTI) is a severe manifestation of peripheral arterial disease (PAD), leading to high risks of amputation, mortality, and reduced quality of life.
  • Current international guidelines advocate for timely revascularization and optimal medical therapy to enhance limb perfusion in CLTI patients.
  • A lack of consensus exists regarding the optimal initial treatment strategy between open bypass surgery (BS) and endovascular therapy (EV) for CLTI, causing clinical uncertainty.

Purpose of the Study:

  • To provide insights into the optimal revascularization strategy for CLTI by analyzing data from the BEST-CLI and BASIL-2 trials.
  • To inform the diabetic foot multidisciplinary team about the latest findings in CLTI management.
  • To highlight the need for personalized treatment approaches in CLTI.

Main Methods:

  • Analysis of patient cohorts from two major trials: BEST-CLI (Best Endovascular versus Best Surgical Therapy in patients with CLI) and BASIL-2 (Bypass versus Angioplasty for Severe Ischaemia of the leg).
  • Inclusion of participants with diverse medical and physical frailty levels.
  • Evaluation of revascularization outcomes based on individual patient characteristics and comorbidities.

Main Results:

  • While definitive conclusions are pending, the trials offer immediate clinical relevance for CLTI management.
  • Findings underscore the necessity of tailoring revascularization strategies to individual patient factors, including comorbidities, risk factors, disease severity, conduit availability, surgical risks, and procedural access.
  • The trials provide valuable data for clinicians managing patients with CLTI, particularly those with diabetes.

Conclusions:

  • An individualized revascularization strategy is crucial for optimizing outcomes in CLTI patients.
  • Early referral to a specialist multidisciplinary team is essential for comprehensive CLTI care in diabetic patients.
  • Comprehensive management should include wound care, infection control, offloading, glycemic control, smoking cessation, and patient education.

Keywords:
CLTIPADchronic limb-threatening ischaemiadiabetic footdiabetic foot ulcerperipheral arterial disease

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