Abstract
Critical limb ischemia (CLI) is a terminal stage of peripheral arterial disease that, in the absence of intervention, may lead to lower extremity amputation or death. Endovascular interventions have become a first-line approach to the management of CLI and have advanced considerably within the past decade. This review summarizes the types of percutaneous devices and the techniques that are available for the management of CLI and the data supporting their use. These include devices that establish and maintain vessel patency, including percutaneous transluminal angioplasty, drug-coated balloons, bare metal stents, drug-eluting stents, bioresorbable vascular scaffolds, and atherectomy; devices that provide protection from embolization; and, cell-based therapies. Additionally, ongoing trials with important implications for the field are discussed.
Highlights
Critical limb ischemia (CLI) is severe arterial insufficiency in the lower extremities, resulting in pain with or without tissue loss for more than two weeks
Given the increased role of endovascular treatment of CLI, this review describes the current percutaneous devices that are available for the management of CLI with a particular focus on infrapopliteal revascularization, which is often required in the management of CLI and highlights the ongoing clinical trials in the field that are anticipated to provide data-driven changes in management for this morbid disease
The 2012 DESTINY trial showed the benefit of an everolimus Drug-Eluting Stents (DES) when compared to Bare Metal Stents (BMS) in below the knee vessels, with higher patency rates at 12 months, as defined by stenosis that was less than 50% on angiogram (85% vs. 54%, p = 0.0001)
Summary
Critical limb ischemia (CLI) is severe arterial insufficiency in the lower extremities, resulting in pain with or without tissue loss for more than two weeks. Class 4–6 and Fontaine Class 3–4 [3] These two classification schemes stratify patients by clinical symptomology and can be used to determine patient’s risk of amputation and likelihood of benefit from revascularization. These schemes address arterial perfusion alone, prompting the development of the Threatened Limb Classification system [WIfI] that is proposed by the Society for Vascular Surgery incorporating wound extent and concomitant foot infection [4]. Several limitations to surgery are recognized: high peri-operative risk due to concomitant medical illness, anatomic challenges of obtaining adequate native grafts, inadequate targets for distal anastomosis, and graft closure In light of these limitations, endovascular approaches have been developed that are considered to be a first-line approach for CLI treatment in properly selected patients. Given the increased role of endovascular treatment of CLI, this review describes the current percutaneous devices that are available for the management of CLI with a particular focus on infrapopliteal revascularization, which is often required in the management of CLI and highlights the ongoing clinical trials in the field that are anticipated to provide data-driven changes in management for this morbid disease
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