Amputation Prevention in Black Populations: Tackling Critical Limb Ischemia

Dr Bill Releford
June 24, 2022

Nearly 2 million people in the USA suffer reduced blood flow due to the severe blockage of the arteries of the lower limbs – a medical condition referred to as critical limb ischemia (CLI). It is common for CLI patients to be hospitalized, and up to 60% of these are readmitted within six months. What’s worse, projections indicate that the prevalence of this condition is soon likely to rise. Given such damning numbers, there is a need for a closer look at CLI, its risk factors, complications, and its threat to limbs and life.

What is Critical Limb Ischemia?

Critical limb ischemia can be described as the final stage of PAD. It is characterized by reduced blood flow in the lower extremities due to blockage of the arteries. 

This chronic condition causes rest pain, and complications may include non-healing ulcers and wounds in the feet and legs. If not treated, these complications could lead to the amputation of a limb.

In addition to the symptoms above, CLI may also be characterized by:

  • Lack of sensation in the feet.
  • Dry, shiny, smooth skin of the feet or legs.
  • Gangrene, often evident through dry, black skin of the feet and legs.
  • Diminished or absent pulse in the feet or legs.
  • Skin infections and non-healing ulcers or sores.

Risk Factors for Critical Limb Ischemia

Certain conditions put individuals at a higher risk of suffering CLI. Most of these are risk factors for arteriosclerosis and include:

  • Advanced age
  • Diabetes
  • Smoking
  • High cholesterol levels
  • Overweight and obesity
  • High blood pressure
  • Sedentary lifestyle

Medical Management of Critical Limb Ischemia

According to the Fontaine classification, CLI is categorized as stage IV PAD, which makes the diagnosis of CLI critical to treatment efforts. Ideally, CLI should be diagnosed objectively and in the early stages of the disease through toe systolic pressures, ABI, MR angiography, CT angiography, or transcutaneous partial pressure of oxygen (TcPO2).

After the diagnosis is confirmed, treatment of CLI is aimed at relieving ischemic pain and healing ischemic ulcers. In turn, these would help salvage limbs, improve one’s function and quality of life, and ultimately increase the chances of survival. Several treatment options are available depending on the severity of the disease.

Endovascular Treatment of CLI

Endovascular therapy is usually minimally invasive and often an option in CLI care and treatment. Most CLI patients have multiple blockages in the arteries below the knee. As such, this treatment often involves puncturing the groin and inserting a tube or catheter into the artery in the groin.

Treatment through endovascular procedures allows access to the diseased part of the artery. Common procedures include angioplasty, stents, laser atherectomy, and directional atherectomy.

Angioplasty involves the insertion of a tiny balloon into the diseased artery through a puncture in the groin. The balloon is then inflated once or severally using a saline solution to help open the artery.

Stents are tubular metal meshes that provide support and are placed in the artery after the opening of the artery through balloon angioplasty. Stents could be balloon-expended or self-expanded and are used depending on the desired flexibility.

Laser atherectomy involves using a laser probe, whose tip vaporizes tiny plaque bits in the artery. On the other hand, directional atherectomy uses a tube with a cutting blade that rotates to get rid of plaque from the walls of the artery. This, in turn, opens the flow channel.

Surgical Treatments of CLI

CLI is often characterized by ulcers and wounds that may require surgical procedures. Surgical treatment is recommended where arterial blockages can’t be treated through endovascular therapy. This form of treatment involves bypassing the affected area using a synthetic graft or vein from the patient.

Other Critical Limb Ischemia Interventions

In addition to arterial revascularization and surgical treatment of CLI, emphasis on lifestyle-based preventive measures is imperative. There are many risk factors for CLI, which is the most severe form of PAD. Here are measures that could help prevent CLI.

Maintain an Ideal Weight

A healthy weight is paramount to cardiovascular health, as overweight and obesity could easily lead to cholesterol build-up. These could also cause arterial blockage, and eventually CLI. While obesity and overweight can contribute to various health issues, such individuals could be at risk of developing CLI.

Quit Smoking

Smoking is another risk factor for PAD as it generally damages the arterial lining and possibly causes a fatty build-up on the walls of the arteries. Besides the potential narrowing of the arteries, smoking also deprives the blood of the essential oxygen supply necessary for the proper functioning of vital organs.

Proper Control of Diabetes

It is estimated that over 34 million people in the U.S.A have diabetes. Unfortunately, these people are four times more likely to develop cardiovascular issues like CLI. Eating a balanced diet with lots of fruits and vegetables, and maintaining a physically active life is a good way to keep diabetes in check and lower the risk of CLI.

Bottom Line

Critical limb ischemia is the most severe form of PAD characterized by rest pain and non-healing ulcers. The most common ways of tackling this condition include arterial revascularization and surgical treatment, but early diagnosis of CLI is critical to treatment outcomes. Additionally, maintaining a healthy weight and keeping diabetes in check are potent ways of lowering the risk of CLI.