Critical Limb Ischemia: Nothing To Give at the Office?

• Leg
• Ischemia
• Amputation
• Quality of life
• Prostaglandins E

The prognosis for patients with chronic critical leg ischemia—that is, pain at rest or established lesions that jeopardize the integrity of the lower limbs—is often poor (1). Psychological testing of such patients has typically disclosed quality-of-life indices similar to those of patients with cancer in critical or even terminal phases (2). It has been estimated that 150 000 patients require lower-limb amputation for critical leg ischemia in the United States annually (3). The prognosis after amputation is even worse (4): In most series, the perioperative mortality is 5% to 10% for below-the-knee amputation and 15% to 20% for above-the-knee amputation. Even when these patients survive, nearly 40% will die within 2 years of their first major amputation. A second amputation is required in 30% of cases, and full mobility is achieved in only 50% of patients who have below-the-knee amputation and 25% of those who have above-the-knee amputation.

These grim statistics are compounded by the absolute lack of effective drug therapy. As concluded in the Consensus Document of the European Working Group on Critical Leg Ischemia (4), “there presently is inadequate evidence from published studies to support the routine use of primary pharmacological treatment in patients with [critical leg ischemia].  …” The patient with critical leg ischemia thus contrasts markedly with nearly all other patients with cardiovascular disorders, for which a plethora of effective medical therapies exists; in the case of critical leg ischemia, the internist has been rendered effete because of the lack of effective pharmacotherapy.

Therapeutic options for critical leg ischemia are consequently limited to percutaneous transluminal angioplasty or surgical revascularization. Unfortunately, many patients with critical leg ischemia are poor candidates for either procedure. Pain at rest or ischemic ulcers are most frequently associated with occlusive lesions of the popliteal or infrapopliteal arteries; …