Restore-CLI

Critical Limb Ischemia (CLI) Facts

What is CLI?

Critical Limb Ischemia (CLI) is often present in individuals with severe Peripheral Arterial Disease (PAD). In the advanced stages of PAD, blood flow to one or both legs can be completely or mostly blocked. This is known as Critical Limb Ischemia. A severe blockage in the legs and feet means the legs do not receive the oxygen or nutrition needed for cellular or skin growth and repair. CLI may cause pain in the legs and feet, and/or foot skin ulcers, and could eventually lead to gangrene. The pain caused by CLI can wake an individual at night. This pain, also called "rest pain," can be relieved temporarily by hanging the leg over the bed or getting up and walking around. If this condition is left untreated, the foot or leg may need to be amputated.

Symptoms

Patients with CLI often suffer from the following:

•	Severe burning or pain in the toes and/or feet when resting
•	Skin sores (ulcers) on the feet or legs that heal slowly or not at all
•	Poor healing response to possible infections, which can lead to tissue death (gangrene)

Prognosis

How is Critical Limb Ischemia diagnosed?

Physicians will assess the severity of a patient’s pain through use of pain scales or visual scales. Physicians also use other methods to diagnose CLI. This includes blood pressure measurements in your ankles and toes. Methods for diagnosis can also include pictures taken of your vessels called an angiography or a Doppler ultrasound.

Treatment

Controlling CLI patients’ pain is very important and is often achieved through improving blood flow of the affected limb or administering large doses of analgesics on a regular basis, e.g., nonsteroidal anti-inflammatory drugs, narcotics or opiates.¹

Critical Limb Ischemia (CLI) Treatment Options

Treatment for CLI can be quite complex and individualized, but the overall goal should always be to reduce the pain and improve blood flow to save the leg, foot or toes. A treatment plan will likely include:

•	Medications: Several medications may be prescribed to reduce the effect of contributing factors such as high blood pressure, high cholesterol and diabetes, and most certainly to reduce the pain. Medications that prevent clotting or fight infections also may be prescribed.
•	Ulcer Care: Treatment will likely include medications and dressings for skin ulcers.
•	Surgery or Endovascular Procedures: Surgical or endovascular procedures can be highly successful methods that restore oxygenated blood flow to the areas of skin breakdown. An endovascular procedure consists of a small incision through which a tube (catheter) is inserted to where the blockages occur. A balloon may be inflated (angioplasty) or the blockage (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.

A bypass graft may be performed in more serious cases. This surgical procedure uses either an artificial tube or one of your veins as a new artery to bring improved blood flow to the needed area. The place where the blood flow is constricted is bypassed.² In a few cases, the surgeon may cut open the artery and scrape the plaque keeping the artery usable. The last recourse would be amputation of a toe, foot or leg. Amputation occurs in about 25 percent of all CLI patients. Since treatment depends on the severity of the disease and many individual parameters, it is essential that someone with skin 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.

If you have vessels that can be used for procedures to improve blood flow, these procedures may work well to reverse the effects of CLI by providing sufficient blood flow to relieve pain and heal skin ulcers. If blood flow is not adequate, patients with CLI can lose limbs or suffer other potentially fatal complications due to gangrene progression or sepsis.³

Approximately 20-30% of CLI patients are not considered candidates for vascular or endovascular procedures and, therefore, amputation is often the only option. Amputation is also considered when there is an absence of distal vessels (the farthest ends of your limbs), especially in the case of advanced distal ischemia associated with a low ankle-brachial index (ABI) value (< 0.3).⁴

References
1. Diehm and Diehm, 2004.
2. See Keeping in Circulation, Fall 2001, Vol. 1 Issue 3.
3. Novo, Coppola and Milio, 2004.
4. Diehm et al, 2004.