Critical Limb Ischemia and Amputations: A Growing Problem

Critical Limb Ischemia (CLI) is a severe obstruction of the arteries which seriously decreases blood flow to the extremities (hands, feet and legs) and has progressed to the point of severe pain and even skin ulcers or sores. The risk of gangrene is imminent. CLI or end-stage lower extremity ischemia continues to be a growing problem in the United States with the number of amputations resulting from CLI increasing by 10 percent each year.

CLI remains a poorly understood, rarely reported and an inconsistently treated major health-care epidemic. As our population in the United States ages, the occurrence of CLI is expected to increase significantly, especially in those with diabetes. Currently, it is estimated that one percent of the population aged 50 and older has or will develop CLI. The number doubles in those individuals aged 70 and over, and increases faster for those aged 80 and older.

Of the 20 million people with diabetes in the United States, one out of every four will face CLI in their lifetime and are at up to 40 times greater risk for amputation than non-diabetics. Within one year of a CLI diagnosis, 40-50 percent will experience an amputation and 20-25 percent will die.

CLI is commonly diagnosed by a podiatrist, vascular medicine, surgeon, woundcare specialist or other referring health-care provider as the result of a poorly healing wound. The actual diagnosis may be confirmed by non-invasive vascular test such as the ankle-brachial index (ABI) test or duplex ultrasound.

Treatment of CLI is important in reducing the risk of amputation, which remains the most common outcome. It is often managed through antiplatelet or statin therapy, wound healing and management of diabetes. However, it usually involves a procedure such as vascular bypass surgery and/or angioplasty/stenting. Appropriate wound care after blood supply is restored or improved should help with healing. At the Fourth Annual CLI Summit held in New Orleans last year, several other treatment options were discussed, including the use of vitamin C, multivitamins, zinc, B12, B6 and folic acid to improve wound healing.* Specific surgical procedures were also discussed, including angioplasty, stenting and atherectomy, with new treatment options being expanded.

Facts about amputation:

• Yearly, 160,000-180,000 major and minor amputations are performed each year in the United States due to CLI. Since 1985, the amputation rate in the United States has increased from 19 to 30 per 100,000 persons each year with a 4-to 5-fold increase in those over the age of 80.
• Worldwide, an amputation is performed every 30 seconds on a person with diabetes.
• Overall, fewer than half of all CLI patients achieve full mobility after an amputation and only one of four above-the-knee amputees will ever wear a prosthesis.
• 30 – 40 percent of all amputees will undergo a second limb amputation within three to five years of their first amputation.
• The 30-day mortality (death) and morbidity (complication) rate after an amputation remains high, which can range for death from 4 – 30 percent and for morbidity from 20 – 37 percent.
• It has been estimated that the total costs of treating CLI in the United States alone is 10 to 20 billion dollars per year

What you can do to prevent amputation:

• Stop smoking (or never start)
• Keep your cholesterol and blood pressure under control
• If you have diabetes, manage it carefully, check your blood sugar often, and see your health-care provider regularly
• If you know you have diabetes or narrowing of the arteries in your leg due to plaque buildup (PAD), you should be aware that these conditions put you at a higher risk for foot ulcers and infection
• The way to help prevent ulcers or infection is to practice good foot care and hygiene

There is much hope for patients with CLI as new treatment options continue to expand that can help prevent amputation. If you have PAD and/or have a wound that has not healed, please see your health-care provider immediately. CLI is a very severe condition and needs comprehensive treatment by a vascular surgeon or vascular specialist. This condition will not improve on its own.

About the Author: David E Allie, MD is the Medical Director and Director of Cardiovascular and Endovascular Surgery at the Louisiana Cardiovascular and Limb Salvage Center, A.P.M.C. Lafayette, Louisiana.

*These treatments have not been approved by the FDA.