(1)
Surgery, Charleston Area Medical Center, WVU Physicians of Charleston, Charleston, WV, USA
(2)
Medicine, Marshall University School of Medicine, Huntington, WV, USA
(3)
Northwestern Medicine, At Central DuPage Hospital, Winfield, IL, USA
(4)
International College of Surgeons, Cardiothoracic and Vascular Surgery, Glen Ellyn, IL, USA
(5)
Medicine and Surgery, West Virginia University, Charleston, WV, USA
(6)
Medicine, Nephrology, Hines VA Hospital, Loyola University, Hines, IL, USA
(7)
Medicine, Loyola University Medical Center and Hines VA, Maywood, IL, USA
(8)
Division of Cardiothoracic Surgery, The University of Tennessee Medical Center, Knoxville, TN, USA
(9)
Research Service, Hines VA Hospital, Hines, IL, USA
(10)
Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL, USA
(11)
Research Service, Edward Hines Jr., VA Hospital, Hines, IL, USA
(12)
Internal Medicine, Illinois State Medical Society, Lombard, IL, USA
(13)
Medicine, Edward Hines Jr., Veterans Affair Hospital, Hines, IL, USA
(14)
Medicine, Cardiology, Loyola University Medical Center, Maywood, IL 60153, USA
(15)
Medicine, Cardiology, Vascular and Endovascular Medicine, Loyola University Medical Center, Maywood, IL, USA
Keywords
MultidisciplinaryTreatmentTeamEtiologyBarrierIntroduction
Although intentionally brief, this chapter is to remind the clinician that the treatment of the patient with critical limb ischemia (CLI ) is inherently multidisciplinary (Fig. 55.1). Depending on the type of lesion and the etiology, one, two, or more consultants will be required.
Fig. 55.1
Multidisciplinary approach to critical limb ischemia
Arterial disease is the etiology of only about 50 % of foot ulcerations. The remainder is due to a variety of causes, including neuropathic/neuroischemic, rheumatological disorders, venous stasis disease, trauma, nutritional, etc. Above the foot ulcers, the role of venous pathology contributing to the ulcer exceeds that of arterial insufficiency [1]. Furthermore, the complexity of the microcirculation and nutritional factors in the development and nonhealing of ulcerations highlights the complexity of these lesions.
It is naïve for the clinician to believe that they can act in isolation when caring for most of these patients. Accurate imaging, wound care, and risk factor modification are all required for the optimization of the limb and patient. Frequently, these patients will require the coordinate involvement of primary care and medical specialties—including endocrinology, nephrology, and rheumatology. Many patients will require endovascular or surgical revascularization. Endovascular therapies have epitomized the overlap of a therapy offered by different disciplines. Rather than interdepartmental conflicts, working together enhances patient care and creates a collaborative learning environment that benefits all. Critical limb ischemia is one end of the spectrum of cardiovascular disease—an extreme with incredibly sick patients. Rather than focusing on our differences, combined programs recognize our common grounds so that these patients are appropriately recognized and treated.
Definition, Incidence, and Epidemiology of Critical Limb Ischemia
Critical limb ischemia may develop consequent to a number of acute or chronic processes including trauma, vascular, or malignant processes that endanger the viability of the extremity. Chronic limb ischemia contributes to significant morbidity and mortality ; it is estimated to account for more than 400,000 hospitalizations in the United States every year. It also carries a 20 % annual mortality [2]. The various degrees of limb ischemia—acute, subacute, or chronic—are a growing problem in United States secondary to an increase in the aging population who have many comorbidities such as diabetes mellitus, hypertension, atherosclerosis, and end-stage renal disease. The afflicted require appropriate and timely intervention to salvage the patient and the extremity after appropriate pre-intervention review.
Multidisciplinary Approach for Treating Patients with CLI Secondary to Obstructive Arterial Disease
Ideal therapy for peripheral arterial occlusive disease is yet to be determined. Standard surgical therapy has been bypass for those patients who have tissue loss or rest pain. However, since the advent of endovascular therapy, minimally invasive therapy has been replacing open revascularization in most institutions. These interventions are only advised after initial noninterventional diagnostic approaches, treatment of any underlying processes (such as infection, edema, wound care, nutritional status, etc.), and appropriate consideration and treatment of non-arterial contributors to the CLI.
In a comparative study between open surgical revascularization and endovascular therapies for femoropopliteal occlusive disease in patients with no previous intervention, surgical bypass for the primary treatment of claudication showed improved freedom from restenosis and symptom relief despite treatment of more extensive disease, but was associated with increased length of stay and wound infection. Medical therapy with statins has shown improved freedom from restenosis and symptom recurrence overall [3].
Yet the only randomized controlled study comparing the bypass versus the angioplasty in patients with CLI is the “Bypass versus Angioplasty in Severe Ischemia of the Leg” [4]. This study concluded that there is no initial difference between angioplasty and open surgery arms regarding the amputation-free survival or overall survival. However after 2 years, patients with surgery did better than angioplasty. Secondary analysis of the same study indicated that both failed endovascular and prosthetic bypass grafts were predictors of failure after intervention. This further points out the need to justify initial intervention and whether it should be delayed or performed as well as the need for further study.
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