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Review
. 2023 Apr 4;12(7):2682.
doi: 10.3390/jcm12072682.

Chronic Limb-Threatening Ischemia and the Need for Revascularization

Raffaella Berchiolli  1 , Giulia Bertagna  1 , Daniele Adami  1 , Francesco Canovaro  1 , Lorenzo Torri  1 , Nicola Troisi  1
Affiliations
Review

Chronic Limb-Threatening Ischemia and the Need for Revascularization

Raffaella Berchiolli et al. J Clin Med. .

Abstract

Background: Patients presenting with critical limb-threatening ischemia (CLTI) have been increasing in number over the years. They represent a high-risk population, especially in terms of major amputation and mortality. Despite multiple guidelines concerning their management, it continues to be challenging. Decision-making between surgical and endovascular procedures should be well established, but there is still a lack of consensus concerning the best treatment strategy. The aim of this manuscript is to offer an overview of the contemporary management of CLTI patients, with a focus on the concept that evidence-based revascularization (EBR) could help surgeons to provide more appropriate treatment, avoiding improper procedures, as well as too-high-risk ones.

Methods: We performed a search on MEDLINE, Embase, and Scopus from 1 January 1995 to 31 December 2022 and reviewed Global and ESVS Guidelines. A total of 150 articles were screened, but only those of high quality were considered and included in a narrative synthesis.

Results: Global Vascular Guidelines have improved and standardized the way to classify and manage CLTI patients with evidence-based revascularization (EBR). Nevertheless, considering that not all patients are suitable for revascularization, a key strategy could be to stratify unfit patients by considering both clinical and non-clinical risk factors, in accordance with the concept of individual residual risk for every patient. The recent BEST-CLI trial established the superiority of autologous vein bypass graft over endovascular therapy for the revascularization of CLTI patients. However, no-option CLTI patients still represent a critical issue.

Conclusions: The surgeon's experience and skillfulness are the cornerstones of treatment and of a multidisciplinary approach. The recent BEST-CLI trial established that open surgical peripheral vascular surgery could guarantee better outcomes than the less invasive endovascular approach.

Keywords: chronic limb-threatening ischemia; endovascular treatment; lower-limb revascularization; peripheral arterial disease; peripheral bypass.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Method used to calculate TBI in patients with CLTI.
Figure 2
Figure 2
Extensive gangrene of the forefoot in patient with severe ischemia (WIfI grade 3).
Figure 3
Figure 3
Infragenicular vein bypass in CLTI patient.
Figure 4
Figure 4
Angioplasty of posterior tibial artery after pedal plantar loop technique.
See this image and copyright information in PMC

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