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Management of Critical Limb Ischemia

Management of Critical Limb Ischemia. From ACC/AHA Guidelines for the Management of PAD. Critical Limb Ischemia. 5 P Pain Pulselessness Pallor Paresthesia Paralysis. Medical treatment. Class III PentoxifyllineI(Trental) is not useful. Class IIb

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Management of Critical Limb Ischemia

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  1. Management of Critical Limb Ischemia From ACC/AHA Guidelines for the Management of PAD

  2. Critical Limb Ischemia 5P • Pain • Pulselessness • Pallor • Paresthesia • Paralysis

  3. Medical treatment Class III PentoxifyllineI(Trental) is not useful. Class IIb IV PGE-1, or iloprost for 7~28 days reduce ischemic pain and facilitate ulcer healing, limited to small percentage of patients

  4. Endovascular Treatment Class I 1.Treat inflow lesions first 2.Treat outflow lesions if infection or symptoms persisted 3.Use vasodilator for augmentation of intra-arterial pressure measurement

  5. Thrombolysis Class I Catheter-based thrombolysis , with acute limb ischemia of less than 14 days Class IIa Mechanical thrombectomy, for adjunctive therapy Class IIb more than 14 days

  6. Surgery for Critical Limb Ischemia Patients with CLI in whom open surgical repair is anticipated should undergo assessment of cardiovascular risk.

  7. Consideration of surgery • Relief of rest pain • Healing of ulcers • Prior revascularization attempts • The type of procedure • The patient’s overall ability to recover

  8. Primary amputation • Significant necrsis of weight-bearing portions of the foot • Uncorrectable flexion contracture • Paresis of the extremity • Refractory ischemic rest pain • Sepsis • Limited life expectancy

  9. Aortoiliac Occlusive Disease • Aortobifemoral bypass • Iliac endarterectomy, patch angioplasty, or aortoiliac or iliofemoral bypass • Axillofemoral-femoral bypass • Vein > Prosthetic conduit • Patency of prosthesis below knee ↓

  10. Infrainguinal Disease • Bypass to the above-knee or below-knee popliteal a. with autogenous v. • The point of origin for bypass: stenosis < 20%, most distal a. • Femoral-tibial a. bypass with v.

  11. Infrainquinal disease • Composite sequential femoropopliteal-tibial bypass, and bypass to an isolated popliteal a. segment • Prosthetic femoral-tibial bypass Class IIa Prosthetic below-knee popliteal artery bypass

  12. Post surgical care • Maximal cardiovascular ischemic risk reduction therapies • Bypass all major distal stenoses and occlusions if symptoms persisted. • F/U at least 2 years, Duplex for vein grafts ABI for synthetic grafts (0.9~1.3)

  13. Cardiovascular Risk Reduction a. Lipid-Lowering Drugs b. Antihypertensive Drugs c. Diabetes Therapies d. Smoking Cessation e. Homocysteine-Lowering Drugs f. Antiplatelet and Antithrombotic Drugs

  14. Lipid-Lowering Drugs Class I: Statin, LDL < 100 Class Iia Statin, LDL < 70 (high risk patients) Fibric acid derivative

  15. Antihypertensive Drugs Class I BP < 140/90 < 130/80 (DM, CRD) Beta blockers are not contraindicated. Class IIa ACEI: reduce risk of cardiovascular disease for symptomatic patients

  16. Diabetes Therapies Class I Foot care Class IIa HbA1c < 7%, for improve cardiovascular outcome reduce microvascular complication

  17. Smoking Cessation Class I Comprehensive smoking cessation intervention

  18. Homocysteine-Lowering Drugs Class IIb Folic acid and Vit.B12: for homocysteine > 14 μmole/l patients

  19. Antiplatelet and Antithrombotic Drugs Class I Aspirin 75~325mg qd Clopidogrel 75mg qd reduce risk of MI, stroke, or vascular death Class III Warfarin is not indicated.

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