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Online ISSN 1827-1847
Sulaiman S. SHOAB, Martin DUDDY, Rajiv VOHRA
Department of Vascular Surgery, University Hospital Birmingham, Birmingham, UK
Critical limb ischemia (CLI) continues to be a significant problem. Amputation rates seem to have stabilized. Increased revascularization does appear to have achieved this result. Advances, especially in diagnostic and interventional radiology have made this possible. Where required and suitable, initial revascularization should be offered by endovascular means. This has reasonable durability and should not compromise any subsequent open repair. The diagnosis of CLI remains essentially clinical. Imaging should be offered initially with Duplex ultrasonography. This is preferably confirmed by MR angiography. CT angiography may be used; however, the radiation exposure has to be considered. Contrast enhanced MR angiography especially using techniques such as STIR has greatly improved utility. The traditional limitations of CT angiography from calcium etc. have also been greatly overcome both from better acquisition as well as postprocessing. In iliac disease results of endovascular therapy may equal that of bypass surgery results. Similar results are possible in femoral disease. In femoro-politeal disease the results of endovascular therapy are only moderately inferior. It also appears that an initial endovascular approach may not compromise subsequent surgical options. This has been made possible by better imaging and interventional equipment. There is considerable 5 year mortality in patients with CLI. This is due to associated cardiovascular and cerebrovascular disease. Primary amputation may be considered in cases with limited life expectancy, dependent living situation, non-ambulatory status, significant necrosis, or spreading infection. It has to be considered that even “minor” amputations may have significant implications. Some higher risk patients with stable CLI may be just treated expectantly.