Critical Limb Ischemic

CRITICAL LIMB ISCHEMIA (CLI)
Timing for Limb Saving Surgery
Dr. dr. Ketut Putu Yasa, SpB, SpBTKV

Divisi Bedah Toraks Kardiak Vaskular Dan Endovaskular
Bagian / SMF Bedah FK UNUD / RSUP Sanglah
Denpasar, Bali
Dipresentasikan pada Surabaya Surgical Update 2017 : “Surgical Aspect of All Non Traumatic Emergency [S-ANTEM]”
Perhimpunan Dokter Spesialis Bedah Indonesia (IKABI) Kord.Wil. Surabaya, 11 – 12 Maret 2017, Hotel Shangri-La Surabaya
TERMINOLOGY
Critical limb ischemia (CLI)
• > 2 weeks of rest pain, ulcers, or tissue loss attributed to
arterial occlusive disease, is associated with great loss of limb
and life
• Pain description : stabbing, hot-burning, tender and cruel-punishing,
localized in the distal part of the foot or in the ischemic ulcer or
gangrenous toe, occurs at night, respond only to opiat or foot dependency
Limb-saving surgery
= Limb-salvage surgey
= Limb-sparing surgery
• Type of surgery primarily performed to avoid amputation
CLI
Unknown direction ?
DIFFERENTIAL DIAGNOSIS OF ISCHEMIC REST PAIN
 Diabetic neuropathy
 Complex regional pain syndrome
 Nerve root compression
 Peripheral sensory neuropathy other than diabetic neuropathy
 Night cramps
 Buerger’s disease (thrombangitis obliterans)
 Local inflammatory diseases : gout, rheumatoid arthritis,
digital neuroma, tarsal tunnel nerve compression or plantar
fasciitis.
Clinical presentation of CLI
Pathologies of CLI
pathophysiological processes :
atherosclerosis and thromboembolic
form :
stenotic, occlusive, and aneurysmal
TREATMENT OF CRITICAL LIMB ISCHEMIA
1. Overall strategy : relieve ischemic pain, heal ischemic ulcers,

prevent limb loss, improve patient function and quality of
life and pro- long survival.
2. Basic treatment : pain control
- Non-narcotic to narcotic and antidepressant
- Regular than on the demand
- Foot dependency position
3. Revascularization
4. Management of ulcers
5. Amputation
- only in selected case
CLI Treatment for Limb Salvage
1. Medical and Pharmacological Treatment

2. Endovascular Treatments
3. Thrombolysis
(Catheter-based thrombolysis, Mechanical thrombectomy devices)
4. Surgery for CLI
1. Inflow revascularization procedure (Aortoiliac Occlusive Disease)
2. outflow revascularization procedure (Infrainguinal Disease)
3. Primary amputation
Intervention procedures of CLI
• Endovascular interventions
– Balloon angioplasty
– Stenting
– Atherectomy
– Catheter-directed mechanical thrombectomy or thrombolysis.
• Surgical procedures
– Surgical removal of thrombus
– Primary surgical repair
– Endarterectomy, with or without patching
– Surgical bypass.
Limb Salvage Surgery for CLI
Inflow revascularization procedure
(Aortoiliac Occlusive Disease)
• Aortobiiliac disease :
– Aortobifemoral bypass
• Unilateral disease :
– Iliac endarterectomy, patch angioplasty, or aortoiliac or iliofemoral
bypass or femoral-femoral bypass
• Extensive aortoiliac disease :
– Axillofemoral-femoral bypass
Limb Salvage Surgery for CLI
Outflow revascularization procedure
(Infrainguinal Disease)
• Bypasses to the above-knee popliteal with autogenous saphenous vein
• Bypasses to the below-knee popliteal with autogenous saphenous vein
• Bypass to tibial or pedal artery ( continous flow without stenosis > 20%)
• Prosthetic femoral-tibial bypass (no autogenous vein is available)
Male , 67 yrs, rest pain, toe gangrene, DM
Fem-Pop bypass . Result : immediate pain relief
CLI
 Not Fit
 Technically not possible
 No benefit
General Principle for Revascularization
• Claudicatio : after trial of exercise and pharmacotherapy.

• Inflow and outflow be assessed
• Inflow lesions revascularized first
• CLI : Straight line flow to the foot.
Important factors to consider revascularization option
• Anatomic level of disease ( TASC classification)

• Degree of ischemia
• Functional status
• Co-morbidities
• Life expectancy
• Technical factors
Candidate for revascularization :

- fit
- technically posible
- no widespread infection or gangren
CRITICAL LIMB ISCHEMIA OUTCOMES
• Traditional outcomes
– Amputation Free Survival
– Patency
• Functional outcome
– Treadmill testing protocols and 6-minute walk tests
• Patient reported outcomes
– Walking Impairment Questionnaire, the Nottingham
Health Profile, PADQOL, and VASCUQOL
• Wound healing outcomes
Peripheral arterial disease and critical limb ischaemia:
still poor outcomes and lack of guideline adherence
4298 amputated patients
Eur Heart J. 2015;36(15):932-938.

Factors of delayed surgery
• Stenoses were detected in 23 (95%) of 24 subjects with
palpable foot pulses
– 13 subjects had one stenosis,
– 10 subjects had two stenoses.
• Stenoses have been detected in 16 (94%) of 17 subjects with
ABI ≥ 1
– 10 subjects had one stenosis,
– 6 subjects had two stenoses.
• Of eight subjects with a TcPo2 value ≥ 50mmHg,
– one stenosis in two subjects
– two stenoses in five subjects.
Faglia at al (1998)
Conclusion
• Critical limb ischemia warrants aggressive
revascularization to reduce risk of amputation
• Early consultation or referal, early limb saving
• Pitfall for delayed surgery

Critical Limb Ischemic

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CRITICAL LIMB ISCHEMIA (CLI)

Timing for Limb Saving Surgery

Dr. dr. Ketut Putu Yasa, SpB, SpBTKV

1. Overall strategy : relieve ischemic pain, heal ischemic ulcers,

1. Medical and Pharmacological Treatment

• Claudicatio : after trial of exercise and pharmacotherapy.

• Anatomic level of disease ( TASC classification)

Candidate for revascularization :

4298 amputated patients

Eur Heart J. 2015;36(15):932-938.

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