Setacci C, de Donato G, Teraa M, Moll FL, Ricco JB, Becker F, Robert-Ebadi H, Cao P, Eckstein HH, De Rango P, Diehm N, Schmidli J, Dick F, Davies AH, Lepäntalo M, Apelqvist J, et al.
European journal of vascular and endovascular surgery : the official journal of the European So.... Date of publication 2011 Dec 1;volume 42 Suppl 2():S43-59.
1. Eur J Vasc Endovasc Surg. 2011 Dec;42 Suppl 2:S43-59. doi:
10.1016/S1078-5884(11)60014-2.
Chapter IV: Treatment of critical limb ischaemia.
Setacci C(1), de Donato G, Teraa M, Moll FL, Ricco JB, Becker F, Robert-Ebadi H,
Cao P, Eckstein HH, De Rango P, Diehm N, Schmidli J, Dick F, Davies AH, Lepäntalo
M, Apelqvist J.
Author information:
(1)Department of Surgery, Unit of Vascular and Endovascular Surgery, University
of Siena, Italy. setacci@unisi.it
Recommendations stated in the TASC II guidelines for the treatment of peripheral
arterial disease (PAD) regard a heterogeneous group of patients ranging from
claudicants to critical limb ischaemia (CLI) patients. However, specific
considerations apply to CLI patients. An important problem regarding the majority
of currently available literature that reports on revascularisation strategies
for PAD is that it does not focus on CLI patients specifically and studies them
as a minor part of the complete cohort. Besides the lack of data on CLI patients,
studies use a variety of endpoints, and even similar endpoints are often
differentially defined. These considerations result in the fact that most
recommendations in this guideline are not of the highest recommendation grade. In
the present chapter the treatment of CLI is not based on the TASC II
classification of atherosclerotic lesions, since definitions of atherosclerotic
lesions are changing along the fast development of endovascular techniques, and
inter-individual differences in interpretation of the TASC classification are
problematic. Therefore we propose a classification merely based on vascular area
of the atherosclerotic disease and the lesion length, which is less complex and
eases the interpretation. Lesions and their treatment are discussed from the
aorta downwards to the infrapopliteal region. For a subset of lesions, surgical
revascularisation is still the gold standard, such as in extensive aorto-iliac
lesions, lesions of the common femoral artery and long lesions of the superficial
femoral artery (>15 cm), especially when an applicable venous conduit is present,
because of higher patency and limb salvage rates, even though the risk of
complications is sometimes higher than for endovascular strategies. It is however
more and more accepted that an endovascular first strategy is adapted in most
iliac, superficial femoral, and in some infrapopliteal lesions. The newer
endovascular techniques, i.e. drug-eluting stents and balloons, show promising
results especially in infrapopliteal lesions. However, most of these results
should still be confirmed in large RCTs focusing on CLI patients. At some point
when there is no possibility of an endovascular nor a surgical procedure, some
alternative non-reconstructive options have been proposed such as lumbar
sympathectomy and spinal cord stimulation. But their effectiveness is limited
especially when assessing the results on objective criteria. The additional value
of cell-based therapies has still to be proven from large RCTs and should
therefore still be confined to a research setting. Altogether this chapter
summarises the best available evidence for the treatment of CLI, which is, from
multiple perspectives, completely different from claudication. The latter also
stresses the importance of well-designed RCTs focusing on CLI patients reporting
standardised endpoints, both clinical as well as procedural.
Copyright © 2011 European Society for Vascular and Endovascular Surgery Urology.
Published by Elsevier Ltd. All rights reserved.
DOI: 10.1016/S1078-5884(11)60014-2
PMID: 22172473 [Indexed for MEDLINE]
