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, Burger’s 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 FIGURE 1D. The ulcer shows FIGURE 1E. After
underwent operative good progress in healing after six weeks of
debridement and began a three weeks of conservative outpatient
regimen of dressing changes therapy. treatment, the ulcer
(gauze dampened with normal is well healed
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.