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A doctor examines a patient's lower leg for signs of Critical Limb Ischemia

What is Critical Limb Ischemia?

Critical limb ischemia (CLI) is an extreme blockage in the arteries of the lower extremities, which greatly reduces blood-flow. CLI is a chronic condition that causes extreme pain in the feet or toes, even while at rest. Additional complications of poor circulation can include sores and wounds that won’t heal in the legs and feet.

If left untreated, symptoms will continue to digress and could result in the amputation of the affected limb. CLI requires medical attention from a professional as the condition will not improve on its own.

The importance of the Continuum of Care model for Limb Salvage

CLI-related conditions are a spectrum. While connected by a common source, conditions on each end of the spectrum are vastly different. Dr. Walker uses the concept of the continuum of care to illustrate the need for early identification and referrals for revascularization.  With today’s technology and medical knowledge, limb salvage has become a safer and more cost-effective alternative to amputations.

What are the symptoms of Critical Limb Ischemia?

In its early stages, Critical Limb Ischemia does not show any symptoms. That is why the first sign of the disease is typically a stroke or transient ischemic attack (TIA), caused by a lack of blood to the brain. Signs of stroke or TIA include sudden numbness in the face or on one side of the body, confusion, trouble speaking, dizziness, blurred vision, or severe headache.

  • Decreased pulse in the legs or feet
  • Rest Pain – Continuous burning discomfort in the legs and feet
  • Gangrene – loss of body tissue due to either a lack of blood flow or a serious bacterial infection
  • Ischemic Ulceration – Arterial insufficiency ulcers on the ankle and/or feet
  • Thickening of the toenails
  • Numbness in feet

Risk Factors associated with Critical Limb Ischemia

The risk factors associate with Critical Limb Ischemia are:

  • Age – Over 70
  • Diabetes
  • Smoking
  • High Cholesterol
  • High Blood Pressure
  • Obesity
  • A Family History of Cardiovascular Disease

How is Critical Limb Ischemia Diagnosed?

An accurate diagnosis of Critical Limb Ischemia is dependent upon the location of the disease. A cardiologist will use one of the following methods to detect and monitor your arterial health.:

  • Auscultation: Physician uses a stethoscope to listen for the presence of a bruit, or “whooshing” sound in the arteries of the legs.
  • Ankle-brachial index (ABI): A quick, non-invasive test used to determine if blood flow may be inhibited in one or both legs.
  • Doppler Ultrasound: A form of ultrasound measuring the direction and rate of blood-flow through the vessels.
  • CT angiography: An advanced X-ray procedure that uses a computer to generate three-dimensional images.
  • Magnetic resonance angiography (MR angiography): A Magnetic resonance angiography is used to generate images of arteries in order to evaluate them for stenosis, occlusions, aneurysms or other abnormalities.
  • Angiogram: A diagnostic test that uses x-rays to take pictures of your blood vessels.

How is CLI Treated?

Endovascular treatments

Endovascular treatments are innovative, less invasive procedures used to treat problems affecting blood vessels.

Minimally invasive endovascular procedures are now the first option for treating Critical Limb Ischemia. The treatment option is dependent upon the location and proportion of the blockages.

Some of the common endovascular procedures used to treat Critical Limb Ischemia are:

  • Angioplasty: A small balloon is placed through a puncture in the groin. The balloon is inflated, using a saline solution, to open the artery. An Angioplasty is a simple and safe solution for patients with CLI. It is also a much less invasive and lower cost procedure.
    Cutting balloon: This procedure is composed of a conventional balloon catheter with micro-blades added to dilate the afflicted area. These micro-blades cut the surface of the plaque, diminishing the force required to dilate the vessel.
  • Stents: Stents or metal mesh tubes are placed in artery during a balloon angioplasty to provide ongoing support.
  • Balloon-expanded: The stent or metal mesh tubes are expanded by use of a balloon.
  • Laser Atherectomy: The tip of a laser probe is used to vaporize small amounts of plaque.
  • Directional Atherectomy: The flow channel is opened by removing plaque from the artery via a rotating cutting blade during a catheter procedure.

Endovascular procedures for treating CLI provide a much shorter recovery time compared to other surgical options. Recovery time from endovascular procedures treating CLI is only one to two days. Most endovascular procedures are conducted on an outpatient level.

Surgical treatments

Some PAD conditions are not favorable for an endovascular procedure. When artery blockages are not suitable, surgical treatment is recommended. Surgical procedures for the treatment of PAD often involves bypass around the diseased segment with either a vein from the patient or a synthetic graft. Patient recovery after a PAD surgical procedure can take several weeks.

Amputation as a last resort

Patients who undergo amputations to limit damage from CLI suffer many negative consequences.

  • 40% chance of dying within 2 years of surgery.
  • 25% chance of requiring long-term care.
  • High cost of treatments, after-care, and therapies.

To increase quality of life, physicians should make every attempt to avoid amputation.

  • Why is Limb Salvage linked with Critical Limb Ischemia (CLI)?

    Current medical consensus suggests amputation is the best way to treat patients with CLI. Dr. Craig Walker of the Cardiovascular Institute of the South, however, has proven that CLI can be treated without amputation.

  • What are the keys to avoiding limb amputation?

    Dr. Walker identifies techniques that help delay or prevent amputations.

    • Early diagnosis and adoption of medical therapies.
    • Nutritional counseling, infection control, and proper wound care.
    • Relieving pressure to the affected limb through cushioning and unloading.

    In some cases, hyperbaric treatment and minor amputations may be needed. 

  • Why are Limb Salvage teams important?  

    CLI and amputation are not inextricably linked. Factors like lifestyle habits, comorbidities, and the progress of the disease should dictate individual treatment plans. A team of medical professionals should evaluate patient cases before granting an amputation. 

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