Critical ischaemia

Patients with severe ischaemia have symptoms such as rest pain or skin necrosis. The extent of the arterial insufficiency can be assessed by doppler pressure index studies and arteriography.

Treatment options include:

• IV drug therapy e.g. vasodilators
• lumbar sympathectomy
• percutaneous balloon angioplasty
• reconstructive arterial surgery
• amputation
• terminal pain relief

NICE state (2):

• if critical limb ischaemia ensure patients are assessed by a vascular multidisciplinary team before treatment decisions are made
• major amputation should not be undertaken in people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular multidisciplinary team
• revascularisation
  • offer angioplasty or bypass surgery for treating people with critical limb ischaemia who require revascularisation, taking into account factors including:
    • comorbidities
    • pattern of disease
    • availability of a vein
    • patient preference
  • do not offer primary stent placement for treating people with critical limb ischaemia caused by aorto-iliac disease (except complete occlusion) or femoro-popliteal disease
  • primary stent placement should be considered for treating people with critical limb ischaemia caused by complete aorto-iliac occlusion (rather than stenosis)
  • use bare metal stents when stenting is used for treating people with critical limb ischaemia
  • use an autologous vein whenever possible for people with critical limb ischaemia having infra-inguinal bypass surgery

Notes:

• endovascular intervention:
  • percutaneous transluminal balloon angioplasty +/- stenting has been shown to be effective in relieving the symptoms of patients with intermittent claudication
    • most common complication following the procedure is a groin haematoma. Bleeding from the groin requiring surgical correction occurs in less than 1% of procedures. Limb loss as a direct result of the intervention should occur in less than 1% of interventions for stable claudicants
• surgery
  • due to the potential risks of surgical intervention, operative treatment is mainly reserved for managing critical ischaemia and debilitating claudication that is unsuitable for endovascular treatments.

Reference:

• 1. BHF Factfile (September 2009). Intermittent claudication and peripheral arterial disease.
• 2. NICE (March 2018). Lower limb peripheral arterial disease: diagnosis and management