Critical Limb Ischemia

The lack of blood due to severe obstruction of the arteries may cause rest pain in the foot or toes. Rest pain is a severe pain that wakes you up at night, every night. It goes away or feels better if you let your leg hang over the side of the bed or even get up and walk around. The severe obstruction of the arteries may also cause the skin to break open and develop sores, ulcers or even gangrene. Chronic pain in the feet, ulcers or gangrene resulting from arterial obstruction is called Critical Limb Ischemia (is KEE mee uh) or CLI.

CLI is a very severe form of peripheral arterial disease (PAD). It can also be a result of Buerger's disease (see page 1). CLI needs comprehensive treatment by a vascular surgeon or vascular specialist. Ignoring it will not help, ever! This is not a condition that will improve on its own. The vascular specialist will need to verify that you have CLI as there are other conditions that may be similar, and treatment will vary. He or she will assess the status of the disease by doing a physical exam, finding out what procedures or treatments have occurred in the past and what other conditions you have such as diabetes, or heart disease. In addition, diagnostic tests will be performed to determine the severity of the disease and to identify the best treatment plan.

Treatment for CLI is very complex and individualized. The overall goal is to reduce the pain and improve blood flow to save the leg, and will likely include:

Medications
Several medications may be prescribed to prevent further progression of the disease and to reduce the effect of contributing factors such as high blood pressure, high cholesterol and diabetes, and most certainly to reduce the pain. Also, medications toprevent clotting, or to fight infections may be prescribed.

Smoking Cessation
If you smoke, stop! It may save your leg and your life! (See the last issue of Keeping in Circulation, Vol.2 Issue 1)

Ulcer Care
Treatment will likely include medications and dressings for ulcers.

Surgery or Endovascular Procedures
In most persons with CLI, surgical or endovascular procedures will be performed so that oxygenated blood can flow again to the areas of skin breakdown. An endovascular procedure consists of a small incision through which a catheter is inserted to where the blockages occur. A balloon may be inflated (angioplasty) or the plaque may be scraped off the artery, or the clot may be removed or broken up (thrombolysis). A wire-reinforced stent may be left in the artery to keep it open. In more severe CLI, a bypass graft may be performed. This is a surgical procedure that uses either an artificial tube as a new artery or one of your veins to bring good blood flow to the needed area, bypassing where the blood flow is constricted. (See Keeping in Circulation, Fall 2001, Vol. 1 Issue 3.) In a few cases, the surgeon may cut open the artery and scrape out the plaque keeping the artery usable. The last recourse would be amputation of a toe, part of the foot, or leg.

Since treatment depends on the severity of the disease and many individual parameters, it is essential that someone with ulcers, or pain in the legs or feet when walking or at rest see a vascular specialist as soon as possible. The earlier a diagnosis can be made, the earlier treatment can be started with less serious consequences.