Journal of Vascular Medicine & Surgery

Critical Limb Ischemia: Toward a Limb-Salvage Centered Approach

Yan Xu^* Department of Vascular Surgery, Fujian Medical University, Fuzhou, China
^*Correspondence: Yan Xu, Department of Vascular Surgery, Fujian Medical University, Fuzhou, China, Email:

Received: 01-Jan-2025, Manuscript No. JVMS-25-28753; Editor assigned: 03-Jan-2025, Pre QC No. JVMS-25-28753 (PQ); Reviewed: 17-Jan-2025, QC No. JVMS-25-28753; Revised: 24-Jan-2025, Manuscript No. JVMS-25-28753 (R); Published: 31-Jan-2025, DOI: 10.35248/2329-6925.25.13.580

Description

The management of Critical Limb Ischemia (CLI) remains one of the most challenging aspects of vascular practice, representing the convergence of advanced atherosclerotic disease, complex comorbidities, and significant socioeconomic barriers to care. Despite technological advances and procedural refinements, major amputation rates for CLI have remained stubbornly high, with more than 50,000 major lower extremity amputations performed annually in the United States. This persistent challenge demands a fundamental reconsideration of our approach to this devastating manifestation of peripheral arterial disease.

The recent transition in terminology from "critical limb ischemia" to "Chronic Limb-Threatening Ischemia" (CLTI) represents more than semantic evolution—it reflects a paradigm shift toward earlier recognition and more aggressive intervention before tissue loss becomes irreversible. This conceptual reframing acknowledges the continuum of disease and emphasizes the urgency of timely revascularization to preserve tissue viability and functional status.

The traditional approach to CLI has focused primarily on hemodynamic parameters and anatomic considerations, with treatment success defined by technical outcomes such as patency and limb salvage. While these metrics remain important, a more comprehensive patient-centered paradigm incorporating functional outcomes, quality of life, and long-term survival is gaining recognition. The BEST-CLI trial has begun to address this broader perspective, evaluating not only traditional endpoints but also functional status, quality of life measures, and cost-effectiveness—data that will refine our understanding of optimal management strategies.

Revascularization options have expanded dramatically in recent decades, with endovascular techniques now offering solutions for increasingly complex anatomic scenarios. The development of specialized crossing devices, re-entry tools, and low-profile delivery systems has enabled successful recanalization of chronically occluded vessels that previously required open bypass or were deemed untreatable. Similarly, advanced atherectomy modalities including directional, rotational, orbital, and laser technologies have broadened our armamentarium for calcified or fibrotic lesions.

Drug-coated balloons and drug-eluting stents have demonstrated promising results in femoropopliteal interventions, though their efficacy in infrapopliteal disease—the most common anatomic pattern in CLI—remains less established. The recent BASIL-2 and BASIL-3 trials have begun to provide contemporary comparative data on endovascular versus surgical approaches and various endovascular modalities, respectively, though definitive guidance remains elusive given the heterogeneity of CLI presentations.

Beyond revascularization, wound care has evolved into a sophisticated subspecialty integrating advanced dressings, negative pressure therapy, cellular and tissue-based products, and hyperbaric oxygen. The recognition that perfusion alone is insufficient for wound healing has led to multidisciplinary limb preservation teams incorporating vascular specialists, podiatrists, wound care experts, infectious disease specialists, and rehabilitation medicine. Centers implementing such integrated approaches have demonstrated improved limb salvage rates compared to traditional siloed care models.

Prevention and early intervention represent another frontier in CLI management. Risk factor modification, particularly smoking cessation and diabetes management, significantly impacts disease progression and intervention outcomes. Implementation of structured surveillance programs for high-risk populations, including diabetic patients and those with prior vascular interventions, can facilitate earlier intervention before tissue loss develops. Similarly, public education initiatives addressing the importance of foot care and prompt evaluation of concerning symptoms may reduce presentation delays.

The socioeconomic dimensions of CLI cannot be overlooked. Significant disparities exist in CLI outcomes across racial, ethnic, and socioeconomic strata, with marginalized populations experiencing higher rates of major amputation. These disparities reflect complex interactions between access barriers, referral patterns, implicit biases, and systemic healthcare inequities. Addressing these disparities requires both system-level policy changes and individual practitioner commitment to equitable care delivery.

Conclusion

The emergence of novel therapeutic modalities offers additional hope for improving CLI outcomes. Cell-based therapies, including autologous bone marrow-derived stem cells and peripheral blood mononuclear cells, have shown promise in early clinical trials for patients with no-option CLI. Gene therapy approaches targeting angiogenic factors such as hepatocyte growth factor and fibroblast growth factor have demonstrated potential to stimulate collateral vessel formation. While these modalities remain investigational, they represent important directions for patients with anatomy unsuitable for conventional revascularization. As we advance our approach to CLI, several principles should guide practice evolution. First, early recognition and prompt revascularization before tissue loss develops improve outcomes. Second, revascularization strategy should consider patient-specific factors including anatomic pattern, comorbidities, functional status, and life expectancy rather than predetermined algorithmic approaches. Third, comprehensive care extending beyond revascularization to include wound management, infection control, offloading strategies, and rehabilitation optimizes functional outcomes. Finally, longitudinal follow-up with surveillance protocols and risk factor management reduces recurrence and disease progression.