Multidisciplinary Management of Chronic Limb Threatening Ischemia

Abstract

Patients with chronic limb threatening ischemia are at high risk for cardiovascular events, mortality, and adverse limb events. A 62-year-old man with diabetes and peripheral artery disease presented with a new foot ulcer with suspicion of infection. Leveraging evidence-based practices, a multidisciplinary team conducted a prompt and thorough evaluation. This collaborative approach facilitated comprehensive medical therapy and interventions for optimal limb outcomes and secondary prevention. The coexistence of diabetes, infection, and ischemia significantly augments the complexity of chronic limb threatening ischemia management. Addressing each of these components in concert with recent clinical practice guidelines and randomized trials can promote optimal outcomes.

Keywords: CLTI; PAD; WIfI; lipid; multidisciplinary team; rivaroxaban.

Graphical abstract

Figure 1

Physiological Vascular Test at Presentation ABI = ankle brachial index; PPG = photoplethysmography; PVR = pressure volume recording.

Figure 2

Left Leg Angioplasty The patient’s angioplasty on day 3 from presentation. (A) Occluded mid SFA on anterograde angiography. (B) Retrograde angiography of distal SFA (distal SFA access). (C) Left SFA is patent with <10% residual stenosis following angioplasty using nitinol and drug-coated balloons. ∗SFA occlusion. SFA = superficial femoral artery.

Figure 3

Patient’s Left Foot at Presentation and on Discharge Patient’s left foot at presentation (A). Left foot with reduced erythema following 5 days of antibiotic therapy and 1 day from revascularization (B).

Figure 4

CLTI Treatment Goals and Components of Care CLTI = chronic limb threatening ischemia.

Figure 5

Patient’s WIfI Classification at Presentation Patient’s WIfI grading and stage. (A) Wound grade 2, ischemia grade 1, and foot infection grade 2 are combined to high-risk clinical stage that reflects high risk of amputation (B) and high likelihood of benefit from revascularization (C). H = high risk; L = low risk; M = moderate risk; SBP = systolic blood pressure; SIRS = systemic inflammatory response syndrome; TcPO² = transcutaneous oxygen pressure; TP = toe pressure; VL = very low risk; WIfI = wound, ischemia, and foot infection; other abbreviation as in Figure 1. ◯ = patient’s grade/stage. (B) Reproduced with permission from Elsevier.