Introduction

Chronic Critical Limb Ischemia (CCLI) is the end

result of arterial occlusive disease, most
commonly atherosclerosis

Atherosclerosis causes of CCLI association with

diabetes (important risk faktor), HT,
hypercholesterolemia, smoking,
thromboangititis obliterans, Burgers disease
and some forms of arteritis

CCLI is a marker for premature death with

mortality rates of 25% at one year, 31,6% at
two years and excess of 60% after three years

Introduction

In diabetes patients :
atherosclerosis develops at a
younger age and progresses
rapidly
Atherosclerosis affects more distal
vessels (profunda femoris,
popliteal and tibial arteries)

Atherosclerosis in distal arteries in

combination with diabetic
neuropathy contributes to the
higher rates of limb loss in diabetic
patients compared nondiabetic
patients

Clinical Presentation CCLI

The development of CCLI

usually requires multiple sites of
arterial obstruction that
severely reduce blood flow the
tissues

CCLI due to critical tissue

ischemia is manifested clinically
as rest pain, nonhealing wounds
or tissue necrosis (gangrene)

The European Working Group on

Critical Limb Ischemia Definition

Management of CCLI

Limb preservation should be the

goal in most patients with critical
limb ischemia.

Conservative treatment
Operative intervention :
revascularization and amputation
Follow-up regimen

Conservative Treatment CCLI

Risk factor modification :

Smoking cessation, blood pressure
control, good glycemic control and
reduction of lipid levels

Antiplatelet therapy :
Decrease the risk of myocardial
infarction, stroke and death
Reduces the rate of arterial
reocclusion after angioplasty or bypass

CASE-1

FIGURE 1A. Right heel ulcer in a 56-year-old

patient with diabetes. The ulcer failed to heal
after three months of conservative treatment.

CASE-1

FIGURE 1B. Segmental pressures and ankle-brachial index (ABI) in the same patient as
in Figure 1a. The ABI of 0.58 on the right and the pulsatile monophasic waveform in the
posterior tibial artery suggested that the ulcer could heal with conservative therapy.

CASE-1

FIGURE 1C. The patient

underwent operative
debridement and began a
regimen of dressing changes
(gauze dampened with normal
saline) three times a day. He
also began wearing a shoe
that allowed ambulation
without direct pressure on the
ulcer. He was followed weekly
in the outpatient clinic.

FIGURE 1D. The ulcer shows

good progress in healing after
three weeks of conservative
therapy.

FIGURE 1E. After

six weeks of
outpatient
treatment, the ulcer
is well healed