Endocrine Considerations in Critical Limb Ischemia

Abstract

Patients with diabetes mellitus (DM) are at high risk of peripheral arterial disease (PAD) as a result of atherosclerotic disease in blood vessels in the lower limb and especially below the knee. Critical limb ischemia (CLI) is the most advanced form of PAD and is characterized by ischemic rest pain or foot ulceration and gangrene. Presence of rest pain, however, is often reduced or absent in patients with DM due to the presence of peripheral neuropathy and many diabetic patients present with foot ulcers or gangrene at the first investigation. The diagnosis of CLI should be supported by non-invasive hemodynamic assessment, such as measure of ankle and toe systolic pressures and transcutaneous oxygen pressure. However, frequent presence of medial arterial calcification of tibial arteries in patients with DM renders ankle systolic pressure measurement of uncertain value. The primary goals of the management of diabetic patients with CLI are pain relief, wound healing, preservation of a functional limb, and reduced cardiovascular morbidity and mortality. These goals are directly related to timely and effective revascularization. The management of CLI in diabetic patients remains a major surgical challenge due to the diffuse and distal pattern of lower extremity atherosclerosis in DM. However, advances in the multidisciplinary care, including an aggressive revascularization intervention, can avoid major amputation in a large percentage of patients.