Lambert MA, Belch JJ, et al.
Journal of internal medicine. Date of publication 2013 Oct 1;volume 274(4):295-307.
1. J Intern Med. 2013 Oct;274(4):295-307. doi: 10.1111/joim.12102. Epub 2013 Jul 22.
Medical management of critical limb ischaemia: where do we stand today?
Lambert MA(1), Belch JJ.
Author information:
(1)Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital and
Medical School, University of Dundee, Dundee, UK.
Critical limb ischaemia (CLI) is a severe form of peripheral arterial disease
(PAD). CLI often causes disabling symptoms of pain and can lead to loss of the
affected limb. It is also associated with increased risk of myocardial
infarction, stroke and death from cardiovascular disease. The aims of management
in patients with CLI are to relieve ischaemic pain, heal ulcers, prevent limb
loss, improve function and quality of life and prolong survival. Here, current
evidence regarding the medical management of CLI is reviewed. Cardiovascular risk
factors should be assessed in all patients with CLI; smoking cessation and
treatment of hypertension, hyperlipidaemia and diabetes all reduce the mortality
rate in those with PAD. Antiplatelet agents (either aspirin or clopidogrel) are
recommended to reduce both the incidence of cardiovascular events and risk of
arterial occlusion. By contrast, routine use of anticoagulation (either warfarin
or heparin) is not recommended. Treatment of the limbs themselves is often more
challenging. Prostanoids may have some efficacy for treating rest pain and for
ulcer healing, and iloprost shows favourable results in reducing the risk of
major amputations, but long-term follow-up data regarding disease progression are
lacking. There is insufficient evidence to support the use of naftidrofuryl or
cilostazol, and pentoxifylline is not beneficial. Furthermore, there is no
evidence of proven benefit of hyperbaric oxygen. A number of angiogenic growth
factors have been studied in Phase I studies and randomized controlled trials
(RCTs). They appear to be safe, but efficacy results have been mixed. Treatment
with stem cells also shows some potential from early trials, but further larger
RCTs are needed to demonstrate clear benefit. Thrombolysis may be an alternative
for patients who develop acute limb ischaemia and are unsuitable for surgical
intervention. However, newer endovascular techniques are likely to have a greater
role in the future.
© 2013 The Association for the Publication of the Journal of Internal Medicine.
DOI: 10.1111/joim.12102
PMID: 23795817 [Indexed for MEDLINE]
