Diagnosis of critical limb ischemia (CLI) is important given the high morbidity and mortality associated with the disease [1]. Once the diagnosis is confirmed, the goals of treatment are to relieve ischemic pain, heal ischemic ulcers, prevent limb loss, improve patient function and quality of life, and prolong survival. Revascularization, whether by surgical bypass or endovascular treatment, should be offered to patients with CLI if the procedure can be tolerated.

Consideration of cost-effectiveness in the management of CLI is important for two reasons. First, care for these patients is costly and laborious [2]. Second, with an aging population in the USA as well as an increasing incidence of diabetes, the incidence of CLI is expected to increase [3].

Multiple resources are utilized for treatment of critical limb ischemia. After confirmatory testing for CLI, the patient needs to be optimized for modifiable risk factors such as smoking cessation, lifestyle modification, and pharmacotherapy [1]. Revascularization , either surgical bypass or percutaneous intervention, is considered first-line therapy if a patient is a suitable candidate. Wound care is utilized along with medical therapy if the patient is stable with uncomplicated tissue loss. Amputation should be performed if a limb is deemed unsalvageable. In addition, rehabilitation and limb prosthesis are necessary in amputees [2]. Management of amputees requires prolonged, longitudinal care. Marston et al. reported a subset of patients with CLI with uncomplicated tissue loss who underwent medical management [4]. Ulcer healing was slow, with only 25 % healed at 6 months and slightly more than 50 % at 1 year. According to a recent report, independent predictors for increased health-care service utilization include older age, female gender, care at the private hospital, longer length of hospitalization, African American race, highest income quartile, and undergoing amputation or debridement [5].

The goals of treatment for peripheral artery disease are to prevent future major coronary and cerebrovascular events and improve leg symptoms [6]. Risk factor modifications, including smoking cessation, exercise, statins, and antihypertensive medications, are known to improve symptoms in peripheral vascular disease. Smoking cessation, blood pressure control, blood sugar control, weight loss, and antiplatelet therapy are important to prevent future vascular events [6].

More specifically, these medical treatment options have also been demonstrated to be effective in the subpopulation with critical limb ischemia (CLI). Shanzer et al. demonstrated the effect of statin use on survival in critical limb ischemia patients [3]. Performing a propensity score matching comparison using the PREVENT III trial population, the investigators found survival advantage at 1 year of 86 % vs. 81 % (Hazard ratio 0.71; CI 0.52–0.90; p = 0.001) in patients who were on statins. Chung et al. demonstrated that despite existing guidelines recommending optimization of atherosclerotic risk factors such as statins, antihypertensive medications, and antiplatelet agents, less than one-third of patients with CLI presented with their risk factors optimally managed [7]. Underscoring the importance of optimal medical management in this patient population, suboptimal medical management at presentation was an independent predictor of major amputation or death (hazard ratio 8.54; CI 2.05–35.65).

The introduction of endovascular treatment for peripheral vascular disease has led to widespread adoption of minimally invasive percutaneous interventions in the treatment of CLI. Although there are many reported benefits to such an approach compared to traditional bypass surgery, questions remain about their long-term durability and rates of re-intervention [8]. There have been multiple efforts to compare the cost-effectiveness of these two strategies.