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The Current State of Critical Limb Ischemia A Systematic Review ONLINE FIRST

Alik Farber, MD1; Robert T. Eberhardt, MD2
[+] Author Affiliations
1Department of Surgery, Boston University Medical Center, Boston, Massachusetts
2Department of Medicine, Boston University Medical Center, Boston, Massachusetts
JAMA Surg. Published online August 17, 2016. doi:10.1001/jamasurg.2016.2018
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Importance  Chronic critical limb ischemia, marked by intractable lower extremity ischemic rest pain and tissue loss, is a highly morbid condition that leads to the loss of ambulation and decreased quality of life. It is associated with a high risk of limb loss and mortality and presents a significant economic burden to society.

Objective  To review the current state of epidemiology, pathophysiology, diagnosis, and treatment of critical limb ischemia.

Evidence Review  An extensive literature search of the subject matter was conducted on material published in English between 1980 and 2016; both landmark and recently published articles were evaluated. Articles were reviewed if they included the terms critical limb ischemia, ischemic rest pain, gangrene, or extremity ulcers.

Findings  Critical limb ischemia represents the end stage of peripheral arterial disease. Because peripheral arterial disease is most commonly caused by atherosclerosis, critical limb ischemia is heavily associated with smoking and diabetes. Revascularization is the cornerstone of therapy to prevent limb amputation, and both open vascular surgery and endovascular therapy play a key role in the treatment of patients with critical limb ischemia. However, few scientific data are available to identify the optimal revascularization strategy, which has led to a significant amount of variability and equipoise in the treatment of this condition. Medical therapy plays a significant role in optimizing coexistent cardiovascular risk factors and a limited role in improving limb outcomes in nonrevascularizable disease.

Conclusions and Relevance  Understanding critical limb ischemia and its treatment strategies is important for providing the best care for affected patients. Currently, ongoing randomized clinical trials in North America and the United Kingdom aim to provide data to support the best management of these patients.

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Figure.
Variability in the Choice of Therapy for Patients With Critical Limb Ischemia and Infrainguinal Peripheral Arterial Disease Among Vascular Quality Initiative Participants

This graph shows the percentage of patients with critical limb ischemia (CLI) and infrainguinal peripheral arterial disease (IPAD) who were treated with a bypass operation. Each point along the graph represents a separate institution participating in the Vascular Quality Initiative (VQI) that provided data. The mean percentage of bypass operations among all VQI centers was 31%.

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