Update on Chronic Limb-Threatening Ischemia (CLTI) Management 2020

1. CHRONIC LIMB THREATENING ISCHEMIA (CLTI) UPDATE 2020 DR. SUPACHOK MASPAKORN VASCULAR UNIT SURGERY CRH

2. CRITICAL LIMB ISCHEMIA (CLI)  CHRONIC LIMB THREATENING LIMB ISCHEMIA (CLTI) 1. Not all patients suffering from this disease are ‘critical’ 2. Severe ischemia is not the only underlying cause (DM, neuro- ischemic ulcer) 3. Risk of amputation doesn’t entirely depend on the extent of ischemia (+ presence of a wound and infection) The 2017 ESC/ESVS guideline on the diagnosis and treatment of PAD has replaced the term critical limb ischemia with chronic limb threatening ischemia (CLTI) 

3. HISTORY OF CLTI ISCHEMIC REST PAIN USUALLY AFFECTS THE FOREFOOT FREQUENTLY WORSE AT NIGHT OFTEN REQUIRES OPIATE ANALGESIA FOR MANAGEMENT IF PRESENT FOR >2 WEEKS AND COMBINED WITH HEMODYNAMIC EVIDENCE OF SEVERELY IMPAIRED PERFUSION (ABI < 0.4*, ABSOLUTE AP < 50MMHG, TP< 30 MMHG) = DIAGNOSTIC OF CLTI ISCHEMIC ULCERATION IS FREQUENTLY LOCATED ON THE TOES AND FOREFOOT GANGRENE USUALLY OCCURS ON THE FOREFOOT

5. PHYSICAL EXAMINATION OF CLTI BUERGER’S SIGN BUERGER’S SIGN, PALLOR OF THE FOOT ON ELEVATION AND RUBOR (SO- CALLED SUNSET FOOT) ON DEPENDENCY PULSE DEFICIT NON-SPECIFIC FEATURES SUCH AS COOLNESS, DRY SKIN, MUSCLE ATROPHY, HAIR LOSS, AND DYSTROPHIC TOENAILS WITH DM, “GLOVE AND STOCKING AND STOCKING” SENSORY, MOTOR, AND AUTONOMIC NEUROPATHY GLOVE WITH FOOT ULCER, “PROBE PROBE- -TO TO- -BONE TEST TEST” SHOULD BE PERFORMED TO ASSESS DEPTH AND THE PROBABILITY OF UNDERLYING OSTEOMYELITIS BONE

8. Eur J Vasc Endovasc Surg (2019) 58, 362-371 A prognostic tool for the one value of revascularization value of revascularization in patients with chronic limb threatening ischemia (CLTI) the one- -year amputation risk year amputation risk and the added the added WIFI CLASSIFICATION 

10. WIFI CLASSIFICATION

15. OUT COME WIFI stage WIFI stage The estimated risk of a The estimated risk of a major amputation after major amputation after one year one year The estimated The estimated one one- -year AFS year AFS Limb salvage after one Limb salvage after one year year I 0 % 83 % 95 % II 8 % 76 % 92 % III 11 % 75 % 91 % IV 38 % 55 % 61 %

16. HOW TO?

19. GLASS: THE GLOBAL LIMB ANATOMIC STAGING SYSTEM

28.  A 65-year-old diabetic patient with a history of smoking presents with an ulcer of the foot. An ABI measurement were 1.8 bilaterally. He does note an occasional “pins and needles” sensation in both feet. On examination, he has a painless ulcer present on the plantar surface of the left foot, underlying the second metatarsal head. The ulcer is deep to the subcutaneous tissue, but no bone is exposed. There is no significant surrounding erythema; minimal granulation tissue is present. His left dorsalis pedis and posterior tibial arterial pulses are absent, but a weak popliteal pulse is present. What is the next step in management? A. LEG ELEVATION AND REASSURANCE B. A COURSE OF BROAD-SPECTRUM ANTIBIOTICS C. WIDE DEBRIDEMENT OF THE WOUND D. SECOND RAY AMPUTATION E. CT OR CATHETER-DIRECTED ANGIOGRAPHY

29.  A 61-year-old male smoker presents to your clinic with complaints of posterior calf pain consistently appearing after walking two blocks. This prevents him from performing many of his activities of daily living, as walking is his primary form of transport. Ankle (ABI) (ABI) were obtained and were found to be greater than 0.9 bilaterally What is the most appropriate next step? Ankle- -brachial indices brachial indices greater than 0.9 bilaterally. A. REASSURANCE AND 1-YEAR FOLLOW-UP B. REPEAT ABIS C. EXERCISE ABIS D. IMAGING OF THE LUMBAR SPINE E. CATHETER-DIRECTED ANGIOGRAPHY