Critical limb ischemia: current challenges and future prospects

Abstract

Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease. It is defined by the presence of chronic ischemic rest pain, ulceration or gangrene attributable to the occlusion of peripheral arterial vessels. It is associated with a high risk of major amputation, cardiovascular events and death. In this review, we presented a complete overview about physiopathology, diagnosis and holistic management of CLI. Revascularization is the first-line treatment, but several challenging cases are not treatable by conventional techniques. Unconventional techniques for the treatment of complex below-the-knee arterial disease are described. Furthermore, the state-of-the-art on gene and cell therapy for the treatment of no-option patients is reported.

Keywords: cell therapy; critical limb ischemia; medical therapy; peripheral arterial disease; revascularization.

Figure 1

Pedal to plantar technique. Notes: Preprocedural angiography (A). Multiple balloon dilatations performed in a pedal to plantar loop manner (B and C). After the rendezvous in the PTa of the antegrade catheter and the retrograde guidewire advanced from the ATA (D and E), further balloon dilatations have been performed in an antegrade manner from the posterior tibial artery (F and G). Final angiography (H). Abbreviation: PTa, posterior tibial artery.

Figure 2

Trans-collateral technique. Notes: Owing to the chronic occlusion of the ATA, in order to avoid damage to the anterior perforator branch of the peroneal artery, which sustained blood flow to the pedal artery (A and B), a retrograde recanalization of the plantar arch and the ATA through the lateral calcaneal branch of the peroneal artery was performed (C–E). After the rendezvous of the antegrade and retrograde guidewires in the ATA, multiple balloon dilatations were done in an antegrade manner (F and G). Patency of the ATA lumen was reestablished at the final angiographic control (H and I). Abbreviation: ATA, anterior tibial artery.

Figure 3

Double approach technique. Notes: Preprocedural angiography showed occlusion of the ATA with patency of the pedal artery via the anterior perforator branch of the peroneal artery (A and B). In order to avoid the dissection of this precious collateral, the subintimal recanalization of the ATA was not extended beyond this level; therefore, a retrograde puncture of the plantar artery was performed (C). After the rendezvous (D) of the guidewires advanced in opposite directions, balloon dilatation (E and F) from the antegrade approach was performed obtaining a direct straight flow to the forefoot (G–I). Abbreviation: ATA, anterior tibial artery.

Figure 4

Distal venous arterialization. Notes: Preprocedural angiography showed patency of the ATA and the peroneal artery with absence of the PTa, medial plantar artery and lateral plantar artery (A and B). After a failed intraluminal attempt, a subintimal recanalization of the PTa was performed, but a reentry in the true lumen of the medial plantar artery was not achieved. Therefore, an entry in the distal plantar vein was obtained (C) and then confirmed by a gentle injection of a contrast medium through the balloon catheter (D). After balloon catheter dilatations of the arteriovenous fistula and the occluded arterial segment (E–F), postprocedural angiography showed patency of the PTa (G) and a good retrograde filling of the small distal venous channels toward the nonhealing wound area of the heel (H). Abbreviations: ATA, anterior tibial artery; PTa, posterior tibial artery.