Introduction

Chronic Critical Limb Ischemia (CCLI) is the end result of arterial occlusive disease, most commonly atherosclerosis Atherosclerosis causes of CCLI association with diabetes (important risk faktor), HT, hypercholesterolemia, smoking, thromboangititis obliterans, Burgers disease and some forms of arteritis

CCLI is a marker for premature death with mortality rates of 25% at one year, 31,6% at two years and excess of 60% after three years

Introduction

In diabetes patients : atherosclerosis develops at a younger age and progresses rapidly Atherosclerosis affects more distal vessels (profunda femoris, popliteal and tibial arteries) Atherosclerosis in distal arteries in combination with diabetic neuropathy contributes to the higher rates of limb loss in diabetic patients compared nondiabetic patients

Clinical Presentation CCLI

The development of CCLI usually requires multiple sites of arterial obstruction that severely reduce blood flow the tissues
CCLI due to critical tissue ischemia is manifested clinically as rest pain, nonhealing wounds or tissue necrosis (gangrene)

The European Working Group on Critical Limb Ischemia Definition

Management of CCLI

Limb preservation should be the goal in most patients with critical limb ischemia.
Conservative treatment Operative intervention : revascularization and amputation Follow-up regimen

Conservative Treatment CCLI

Risk factor modification :

Smoking cessation, blood pressure control, good glycemic control and reduction of lipid levels

Antiplatelet therapy :
Decrease the risk of myocardial infarction, stroke and death Reduces the rate of arterial reocclusion after angioplasty or bypass

CASE-1

FIGURE 1A. Right heel ulcer in a 56-year-old patient with diabetes. The ulcer failed to heal after three months of conservative treatment.

CASE-1

FIGURE 1B. Segmental pressures and ankle-brachial index (ABI) in the same patient as in Figure 1a. The ABI of 0.58 on the right and the pulsatile monophasic waveform in the posterior tibial artery suggested that the ulcer could heal with conservative therapy.

CASE-1

FIGURE 1C. The patient underwent operative debridement and began a regimen of dressing changes (gauze dampened with normal saline) three times a day. He also began wearing a shoe that allowed ambulation without direct pressure on the ulcer. He was followed weekly in the outpatient clinic.

FIGURE 1D. The ulcer shows good progress in healing after three weeks of conservative therapy.

FIGURE 1E. After six weeks of outpatient treatment, the ulcer is well healed