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Outcomes in the Management of Chronic Limb-Threatening Ischemia -- Analysis of the BEST-CLI Trial

Published:January 02, 2023DOI:https://doi.org/10.1053/j.jvca.2022.12.034
      PERIPHERAL ARTERY DISEASE (PAD) remains a global concern, and the perioperative management of patients presenting for lower extremity vascular occlusion presents significant challenges to anesthesiologists and intensivists. A recent study by Song et al. estimated an international prevalence for individuals with PAD >25 years old at 5.56%, and >236 million people are diagnosed with this disease.
      • Song P
      • Rudan D
      • Zhu Y
      • et al.
      Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: An updated systematic review and analysis.
      Chronic limb-threatening ischemia (CTLI) represents a subset of PAD that is defined by the presence of the following criteria: (1) rest pain associated with arterial insufficiency, (2) tissue loss in the form of ulceration or gangrene associated with arterial insufficiency, and (3) reduced perfusion demonstrated on noninvasive vascular imaging (ankle-brachial index <0.4, toe pressure <50)
      • Conte MS
      • Bradbury AW
      • Kolh P
      • et al.
      Global vascular guidelines on the management of chronic limb-threatening ischemia.
      established by the TransAtlantic Inter-Society Consensus.
      • Dormandy JA
      • Rutherford RB.
      Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC).
      ,
      • Azuma N.
      The diagnostic classification of critical limb ischemia.
      Of note, CTLI is often used interchangeably with CLI (critical limb ischemia), although CTLI is widely accepted as the more clinically appropriate terminology. Chronic limb-threatening ischemia is graded based on the Rutherford classification; grade 4 includes those with rest pain alone, grade 5 includes those with minor tissue loss, and grade 6 includes those with major tissue loss. Chronic limb-threatening ischemia is associated with a risk of amputation, significantly higher than that of PAD without CTLI, or other causes of nontraumatic amputation.
      • Creager MA
      • Matsushita K
      • Arya S
      • et al.
      reducing nontraumatic lower-extremity amputations by 20% by 2030: Time to get to our feet: A policy statement from the American Heart Association.
      The 30-day amputation-free survival rate reduces steadily with worsening ischemia; 100% for grade 4, 83% for grade 5, and 41% for grade 6, with an overall 5-year amputation-free survival rate of 27%.
      • Howard DP
      • Banerjee A
      • Fairhead JF
      • et al.
      Population-based study of incidence, risk factors, outcome, and prognosis of ischemic peripheral arterial events: Implications for prevention.
      A large percentage of those with PAD and chronic limb-threatening ischemia present without a prior PAD diagnosis and lack implementation of these simple measures. Both amputation and treatment translate to increased healthcare costs, but major amputation is associated with significantly higher healthcare costs as compared with revascularization.
      • Hirsch AT
      • Haskal ZJ
      • Hertzer NR
      • et al.
      ACC/AHA Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): A collaborative report from the American Associations for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease)–summary of recommendations.
      Although amputations will never be eliminated entirely, timely revascularization is critical in CTLI and always somewhat urgent.
      • Creager MA
      • Matsushita K
      • Arya S
      • et al.
      reducing nontraumatic lower-extremity amputations by 20% by 2030: Time to get to our feet: A policy statement from the American Heart Association.
      ,
      • Mustapha JA
      • Katzen BT
      • Neville RF
      • et al.
      Determinants of long-term outcomes and costs in the management of critical limb ischemia: A population-based cohort study.

      Key Words

      Abbreviations:

      CTLI (Chronic Limb-Threatening Ischemia), CLI (Critical Limb Ischemia), PAD (Peripheral Artery Disease), QOL (Quality of Life)
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