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.
1.
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)
2.
established by the TransAtlantic Inter-Society Consensus.
3.
,4.
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.
5.
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%.
6.
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.
7.
Although amputations will never be eliminated entirely, timely revascularization
is critical in CTLI and always somewhat urgent.
- 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.
J Vasc Interv Radiol. 2006; 17 (quiz 1398): 1383-1397
5.
,8.
Key Words
Abbreviations:
CTLI (Chronic Limb-Threatening Ischemia), CLI (Critical Limb Ischemia), PAD (Peripheral Artery Disease), QOL (Quality of Life)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: January 02, 2023
Publication stage
In Press Corrected ProofIdentification
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© 2022 Published by Elsevier Inc.
