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Northside Cherokee 2 nd Annual CV Summit. Scott R. Beach, MD FACC. Peripheral Arterial Disease. Affects over 8 million Americans Affects 12% of the general population and 20% of those > 70 years old Prevalence continues to increase as baby boomer generation ages. Critical Limb Ischemia.

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peripheral arterial disease
Peripheral Arterial Disease
  • Affects over 8 million Americans
  • Affects 12% of the general population and 20% of those > 70 years old
  • Prevalence continues to increase as baby boomer generation ages
critical limb ischemia
Critical Limb Ischemia
  • Subset of PVD patients
  • Prevelance is 1-2% of patients with PVD over the age of 50
critical limb ischemia1
Critical Limb Ischemia
  • Blood flow is insufficient to meet tissue oxygen demands
  • Ischemic injury occurs in tissues with the least blood supply and results in necrosis
  • Local and systemic inflammatory response
  • Compensatory mechanisms:

post stenotic arteriolar vasodilatation

collateral circulation

critical limb ischemia2
Critical Limb Ischemia
  • Acute ischemia – sudden decrease is blood flow that causes a potential threat to limb viability – rest pain, ischemic ulcers, and/or gangrene who present w/i 2 weeks of event
  • Chronic ischemia – similar manifestations as actue ischemia but > 2 weeks.
critical limb ischemia3
Critical Limb Ischemia
  • Mortality approaches 25% at 1 year after diagnosis
  • Additional 25% require major amputation
  • Amputation increases morbidity and mortality – 50% mortality at 5 years
  • Only 65% BKA amputees ambulatory 1 yr
  • Only 29% AKA amputees ambulatory 1 yr
rutherford classification
Rutherford Classification
  • Stage 0 – Asymptomatic
  • Stage 1 – Mild Claudication
  • Stage 2 – Moderate Claudication
  • Stage 3 – Severe Claudication
  • Stage 4 – Rest Pain
  • Stage 5 – Ischemic ulceration not exceeding the digits of the foot
  • Stage 6 – Severe Ischemic ulcers or gangrene
  • Usually seen when two or more levels of the distal arterial tree has a significant stenosis or occlusion.
  • Multi level disease promotes severe ischemia by reducing the effectiveness of collateral flow and lower distal systolic driving pressures
cli treatment goals
CLI treatment goals

Pain Relief

Heal Wounds

Promote / Protect


Save a LIMB Save a Life

clinical presentation of cli
Clinical Presentation of CLI
    • Rest Pain - Pain in foot usually when limb is elevated and relieved with dependency
  • Ulceration – Distal areas of extremities such as tip of toes, severe pain, dry, poor vascularity
  • Gangrene – Devitalized tissue
avoid at all cost
Avoid at all Cost!

BKA patient has 50% mortality at 5 years

Estimated > 50% increase in energy expenditure in order to

Ambulate after BKA

interventional options
Interventional Options
  • Angiogram required to formulate “game plan”
  • Must evaluate inflow and outflow, usually multi-level disease
  • Treat inflow lesions first
  • Must optimize risk factors and anti platelet therapies
equipment basic needs
Equipment : Basic Needs
  • Sheaths
  • Guidewires
  • Crossing catheters
  • PTA balloons
  • Stents
  • Re-entry devices
  • Athrectomy devices
tibial interventions
Tibial Interventions
  • Retrograde
  • Antegrade
  • Crossing the lesion
  • Pedal access
  • Use of CTO devices
  • Subintimal vs intraluminal approach
economics of limb salvage
Economics of Limb Salvage
  • Limb salvage revascularization is expensive, but better than the alternative of primary amputation.
critical limb ischemia4
Critical Limb Ischemia
  • 1-year mortality for patients with CLI is 25% (mainly cardiac events)
  • The economic burden is high for patients with CLI
  • The median cost of medical care for a patient following an amputation is estimated to be twice that of a successful limb salvage
goals of endovascular treatment
Goals of endovascular treatment
  • Increase tissue perfusion
  • Provide blood flow to affected area to faciliate healing
  • Achieve resolution of rest pain and gangrene
  • Improve patient function
  • Prevent limb loss
diagnostic testing
Diagnostic Testing
  • ABI/ PVR
  • Ultrasound
  • CTA/ MRA – good for inflow but bad for outflow
  • Angiogram – provides most accurate road map for developing a plan for each individual
advantages of endovascular treatment
Advantages of Endovascular Treatment
  • Minimally invasive
  • Avoidance of general anesthesia
  • Minimal risk of wound infection
  • Minimal recovery time
  • Minimal hospital stay, many going home the same day
good news
Good News

Goodney, JVS 2009; 50:54-60

revascularization trends
Revascularization Trends

Geraghty et al MVSS 2005

post revascularization plan
Post revascularization plan
  • Check distal pulses
  • Evaluate for possible complications of revascularization both endovascular and surgical
  • Patient education
post operative period
Post Operative Period
  • Graft occlusion – acute rest pain may be initial presentation, or sudden motor loss/ limb weakness
  • Surigcal incisions – must be kept clean and dry. Observe for signs of infection (cellulitis, elevated WBC, drainage)
  • Lymphatic injury – clear, pale yellow drainage, lymphocele
post operative
Post operative
  • Hematoma
  • Pseudoaneurysm
  • Sphenous neuropathy – pain along the medial aspect of the lower part of the thigh and leg, usually resolves in 3-6 months
foot care
Foot care
  • Alleviate heel pressure
  • No bare feet!
  • Apply lubricating cream to legs and feet
  • Gangrenous lesions must be kept clean and dry
  • Avoid heating pads, cold packs, and any adhesives
take home message
Take home message
  • For patients who present with CLI, it is imperative to move quickly and consult an endovascular specalist
  • Positive outcomes require the cohesive team of endovascular specialists, podiatry, wound care, infectious disease specalists, and primary care physicians.