ABSTRACT

Critical Limb ischemia is an advanced form of Peripheral Arteral Disease that is constituting a major healthcare problem worldwide.1 Peripheral arterial disease affects over 200 million people globally and over 12 million people in the United States.2 CLI is the most severe manifestation of Peripheral arterial disease. Poorly management and delayed presentation of patients with CLI can result in major amputations. Over 200,000 amputations are performed in the USA alone, and globally the numbers are alarming. In certain developing countries, the primary amputation rates can be as high as 65 to 80%.

The clinical presentation of CLI include chronic ischemic pain, rest pain, ulcers, gangrene with minimum duration of 2 to 4 weeks. The dominant pathology is atherosclerosis with advanced calcification of the of the vessels and multi-segmental disease involving aorta, iliac, femoral, or tibial arteries. Some of the risk factors include genetics, smoking, atherosclerosis, sedentary lifestyle. Endovascular options for therapy have definitely improved and evolved since the early 1990’s, but hybrid and open bypass options can still play in significant role in some cases.

The primary treatment strategy in CLI revolves around whether the limb is salvageable, worth saving, feasible for revascularization, and the risk to benefit ratio of revascularization. Thorough clinical evaluation, appropriate work up, including ultrasound, CT angiography, and catheter angiography are essential as part of the pre-operative planning.

Enormous challenges financial abound in many rural community hospitals in the availability of vascular surgeons and required resources for effective treatment of CLI patient. Creative thinking outside the box in utilization of available resources and collaborative relationship with hospital administration are crucial for success.

Methods: Retrospective review of CLI cases in Community Hospital setting in Rural America.

Results: Our experience and outcomes in Appalachia, WV, indicate high success rates with early intervention in institutions that have the basic Endovascular toolbox.

Conclusion: A variety of treatment options can be tailored to meet the challenges of advanced CLI. The use of Endovascular Therapy has significantly evolved and hybrid and open strategies when necessary can increase the chances of limb salvage and minimize amputations.