Current And Emerging Options For Intervention In CLI

Levester Kirksey, MD, and Michael Troiano, DPM

Treatment for peripheral arterial disease (PAD) and particularly critical limb ischemia (CLI) involves the collaboration of a multidisciplinary team and consideration of both new and existing interventions. These authors explore the potential of catheter-based interventions and other technologies to salvage limbs.

As surgical treatment options become increasingly more consumer driven, it is imperative that practitioners step back and review the role of historic and proven treatments in comparison with new and innovative technology. When it comes to the treatment of peripheral arterial disease (PAD), we find ourselves in the “eye of a storm” characterized by rapid advances in minimally invasive technology.

   The treatment of PAD necessitates a collaborative and multidisciplinary approach. This involves podiatrists and vascular practitioners employing the most effective surgical and wound care strategies. The common goals of practitioners in managing this challenging condition should be consistently high rates of wound healing and limb salvage.

   For the past five years, it has been increasingly more common for patients to enter the office with a clear expectation about whatever treatment is appropriate for their given malady. Access to Internet-based sources of medical information, direct to consumer advertising and local news health reports are some of the more common sources of patient education. Direct to consumer marketing has been a very effective tool in increasing public awareness of disease states and the medical products that treat them. To be fair, in our experience, most patients are very reasonable when the physician’s ultimate recommendation differs from their preconceived expectation.

   Our multidisciplinary wound care center, the Penn Wound Care Center (part of the University of Pennsylvania Health System) has a collaborative team model. The multidisciplinary model, directed by our expert podiatric colleagues, has been and continues to be the most important factor responsible for an excellent rate of limb salvage in patients with PAD.

Re-Examining The Goals Of Revascularization

In regard to the treatment of severe chronic limb ischemia (CLI) associated with significant tissue loss, the primary goal for the revascularization is guided by an unambiguous, longstanding vascular surgical dictum: Provide maximal, sustained blood flow directly to the wound bed. Once this occurs, our podiatric colleagues have the best chance of healing a wound. Of course, the healing may take place over a long period of time and require meticulous wound care.

   In the rush to utilize innovative catheter-based technology and apply it broadly in the treatment of PAD, there is a concern that we have forgotten the ultimate goal of advancing patient care. In this case, our goal is to heal wounds. If we are able to merge the goal of healing a wound with a catheter-based technology, this creates a mutually beneficial circumstance. However, we must never lose sight of the fact that healing the wound is the primary goal.

   Historically, in the treatment of CLI, our best indicator of success following open surgical revascularization has been the restoration of a palpable pulse in the foot. There is no difference in what type of bypass one performs as long as pulsatile and direct inline flow to the wound bed is the desired and attained goal.

   In the case of the longstanding diabetic patient with non-compressible and calcified vessels, the graft pulse may not be palpable. In these cases, the acceptable surrogate findings have been the return of normal pressure waveforms by noninvasive testing and the intraoperative confirmation of brisk bleeding by our podiatric colleagues at the time of debridement or resection.


Reading this article made me think of this idea. The Council of Podiatric Medical Education (CPME), the Council of Teaching Hospitals (COTH), the American Podiatric Medical Association (APMA, and the National Board of Podiatric Medical Examiners (NBPME) should meet together to recommend that podiatric residents should learn vascular bypass surgery techniques, namely the popliteal-dorsalis pedis bypass surgical procedure.

I feel that podiatry residencies should not only perform orthopedic and plastic surgeries on the foot, ankle, and leg but also neurological and vascular surgeries on those gross anatomical structures as well. Podiatry residents should perform vascular bypass surgeries on the popliteal artery, posterior tibial artery, and the dorsalis pedis artery, and peripheral nerve surgeries such as the tibial nerve, deep peroneal nerve, sural nerve, saphenous nerve, and superficial peroneal nerve, and the peripheral nerves to the foot.

Podiatry residencies should incorporate plastic surgery, orthopedic surgery, vascular surgery, and neurosurgery techniques relevant to the leg, ankle, and foot. This way, podiatrists will become better surgeons.

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