The Path from Art to Evidence in Treating Critical Limb Ischaemia — Reflections on 35 Years' Experience

Abstract

despite numerous attempts, chronic critical limb ischaemia (cli) has not been unequivocally defined as yet. its epidemiology is poorly investigated and its prevalence probably higher than anticipated. it is accompanied by high mortality and morbidity irrespective of the way it is treated. its management is very expensive. additionally, the prevailing diabetes epidemic is increasing the need for revascularizations although there is a clear lack of evidence as to when to revascularize an ulcerated diabetic foot. The fast development of endovascular techniques blurs the vision as the window of opportunity for gathering proper evidence keeps narrowing. The notion of endovascular artistry prevails, but attempts to conduct proper studies with clear definitions, strict criteria and appropriate outcome measures in a standardised manner should continue -preferably using propensity scoring if randomised controlled trials are not possible.This review highlights some of the steps leading from art to evidence and illustrates the difficulties encountered along the path. in parallel with this overview, the progress of the treatment for cli in finland is described from the perspective of the work concluded at helsinki University central hospital.

Critical Limb Ischemia Treatment Strategies in Diabetics: Present Deeds and Future ChallengesCritical Limb Ischemia Treatment Strategies in Diabetics: Present Deeds and Future Challenges

“…In sum, critical limb ischemia invariably unfolds a multifarious limb-threatening phenomenon particularly pictured in diabetic patients that always have and will request multidisciplinary advises [17,47,48] and high-priority local wound and revascularization treatment [17,37,45,47].…”

What Can I Do With a Patient With Diabetes and Critically Impaired Limb Perfusion Who Cannot Be Revascularized?

“…However, if an exclusively conservative approach is applied in patients with CLI, almost 50% will end up with major amputation within 1 year. 14 Encouraging patients to obtain a second opinion from a specialized interdisciplinary team in case of proposed major amputation of the lower extremity might contribute to further reduction of such events. In addition, a number of alternative treatment options exist, which have to be validated for potential application in each individual patient case due to absence of profound evidence and lack of uniform guideline declarations.…”

“…The term nonreconstructible extremity is therefore rarely used nowadays, which is directly related to the skill and aggressivity to achieve revascularization. 14…”

Endovascular technologies and reconstructive interventions on profound femoral artery at revascularization of multilevel stenotic-occlusive process of infrainguinal arterial channel

“…However, generally accepted tactics in the treatment of patients with atherosclerotic stenoticocclusive process of the infrainguinal arterial bed are not defined [1]. This is due to the multilevel stenotic-occlusive process of the main arterial bed of the lower extremities, the combination of stenotic-occlusive process of different segments of the arterial bed [6], the condition of collateral blood flow, inflow and outflow pathways, [4]. When choosing the scope of surgical treatment all the features of the multilevel stenotic-occlusive process of the infrainguinal arterial bed should be taken into account.…”