Critical Limb Ischemia by Marc Bosiers, Peter Schneider

By Marc Bosiers, Peter Schneider

Protecting either noninvasive and surgical procedure choices, severe Limb Ischemia defines sensible instructions for a multidisciplinary method of serious limb ischemia, and follows a step by step description of the most recent recommendations. issues lined comprise: balloon angioplasty and stenting cryoplasty pharmacotherapy topical cures mixed with hyperbolic oxygen therapy endovascular concepts ideas for leg revascularization presents vascular surgeons, basic and interventional cardiologists, interventionalists, radiologists, podiatrists, and endocrinologists a important source for day-by-day perform.

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This had the same resting ankle pressure limit but added the possibility of measuring the toe pressure, which had to be below 30 or 40 mmHg for patients with ulcers or gangrene or “a barely pulsatile ankle or metatarsal plethysmographic tracing” (6). Another definition of chronic CLI was developed in a European Consensus Document that selected a common pressure level (50 mmHg ankle and 30 mmHg toe pressure) to define a group of patients who would inevitably require amputation in the absence of successful revascularization (7).

Invasive tests can clearly demonstrate occlusive disease, but are poor at reflecting the physiological changes that result. Objective, noninvasive tests can accurately reflect hemodynamic changes resulting from occlusive disease and indicate distal perfusion. They are therefore an essential addition to the criteria employed in defining chronic critical lower limb ischemia. 27 28 Williams TABLE 1 Summary of Advantages and Disadvantages for Noninvasive Assessments Laboratory Radiology Advantages General Relatively low cost Can reduce requirement of contrast imaging Ease of availability No radiation Low risk, noninvasive Nontoxic/No contrast Potential quantitative severity measurement Post-intervention testing and monitoring Close patient contact Small probes and equipment Generally limited availability Radiation exposure (CT, DSA) Higher risk (intravenous/arterial puncture) Potential toxicity related to contrast Generally qualitative measurement Hazardous and restricted use Patient can be isolated Confined space—claustrophobia risk Color Duplex imaging Reflect severity of hemodynamic change Image vessel wall and surrounding tissue Reflect anatomical change mainly Only MRþ/À CT image tissues Doppler waveform analysis Reflect severity of hemodynamic change Relatively easy to perform Reflect anatomical change mainly Complex procedures Distal perfusion indicators Indicate perfusion close to point of interest Continuous monitoring possible No measurement of perfusion Restricted—generally brief Disadvantages General Results very operator dependent Generally no therapeutic action (except ultrasound-guided intervention) Minimal operator dependency Potential therapeutic intervention (DSA/ angioplasty/stenting) Color Duplex imaging Interpretation of stored images difficult Patient obesity—potential reduced efficacy Images easily inspected after test Obesity has less influence Doppler waveform analysis Vessel calcification can compromise tests Arterial anatomical detail limited Calcification less problematic Good arterial anatomical detail Segmental pulse and pressure tests Vessel calcification can compromise tests Arterial anatomical detail limited Practical issues regarding cuff application Cutaneous sensors sensitive to environment (potential for variation in readings) Cutaneous perfusion indicators Restricted use in clinical setting Small study area (vulnerable to local variations in perfusion) Cutaneous sensors sensitive to environment (potential for wide variation in readings) Cutaneous perfusion tests generally slow Calcification less problematic Good arterial anatomical detail No similar restriction (lower limb edema, cellulitis, ulceration) No similar sensitivity issues No similar concerns No similar concerns No similar environment issues Tests performed relatively quickly Abbreviations: MR, magnetic resonance imaging; CT, computerized tomography; DSA, digital subtraction angiography.

The authors included an ankle systolic pressure of less than 40 mmHg in patients with chronic ischemic rest pain and an ankle systolic pressure less than 60 mmHg in patients with ulcers or gangrene. Patients with diabetes were excluded from the definition and no other report was applied to such patients. The definition was based on the concept of limb-threatening ischemia, a term used to describe ischemia of such severity that in the absence of a successful revascularization the leg will require a major amputation.

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