WOUND HEALING Critical Evaluation of Endovascular Surgery for Limb Salvage Layla C. Lucas, M.D. Joseph L. Mills, Sr., M.D. Tucson, Ariz. Summary: Rest pain, tissue loss, and gangrene are manifestations of critical limb ischemia caused by peripheral arterial disease and define a patient subgroup at highest risk for major limb amputation. Patients with nonhealing lower extremity wounds should be screened for the risk factors for peripheral arterial disease and offered noninvasive vascular testing. The diagnosis of critical limb ischemia man- dates prompt institution of medical and surgical management to achieve the best chance of limb salvage. Surgical intervention has evolved from primary amputation to open bypass to the present era of endovascular therapy. The goals of surgical bypass and endovascular therapy are to improve perfusion sufficiently to permit healing. Despite poorer patency rates and the more frequent need for reinterven- tion, endovascular therapy has been shown in multiple retrospective studies to achieve limb salvage similar to open bypass. Only one large, prospective, random- ized controlled trial exists comparing open bypass with endovascular therapy: The Bypass versus Angioplasty in Severe Limb Ischemia of the Leg (BASIL) trial. Close clinical surveillance and serial monitoring of limb perfusion by means of noninvasive arterial studies are needed to determine the need for further vascular intervention. Limb salvage patients suffer from multiple comor- bidities and benefit from a multidisciplinary, team approach to care. (Plast. Reconstr. Surg. 127 (Suppl.): 163S, 2011.) R est pain, tissue loss, and gangrene represent the end stages of chronic lower extremity isch- emia. These three physical manifestations, termed “critical limb ischemia,” correspond to pa- tients who are at imminent risk for lower extremity amputation. Although primary amputation may of- fer an immediate solution to critical limb ischemia, in functional patients it negatively affects their qual- ity of life for most such individuals. Critical limb ischemia patients suffer from multiple comorbidities that shorten their life span (Fig. 1). The 1-year mor- tality rate for someone presenting with critical limb ischemia is 20 percent, and 5-year mortality is 50 percent, 1 worse than for many forms of cancer. 2 Ef- forts to effect limb salvage and prevent amputation must encompass a multidisciplinary approach to manage patients with critical limb ischemia both medically and surgically so that they may enjoy the remainder of their life with the use of their legs. Endovascular therapy currently plays a large role in the surgical treatment of critical limb ischemia. IDENTIFICATION OF CRITICAL LIMB ISCHEMIA Peripheral arterial disease is primarily caused by atherosclerosis and manifests itself in the lower extremities in varying degrees of se- verity. It can be asymptomatic in patients who are sedentary or who have well-developed col- lateral vessels. Peripheral arterial disease can also progress to claudication or critical limb ischemia. Critical limb ischemia is clinically de- fined as persistent, recurring ischemic rest pain present for at least 2 weeks, ulceration or gan- grene of the foot or toes, and is commonly as- sociated with ankle systolic pressure less than 50 mmHg or toe systolic pressures less than 30 mmHg. 1 Various classification schemes catego- rize peripheral arterial disease symptoms into stages. The Fontaine classification places critical limb ischemia in stages III and IV; the SVS- Rutherford classification places critical limb ischemia in stages 4 to 6 (Table 1). Once it has developed, it is paramount that optimal medical From the University of Arizona Health Sciences Center. Received for publication September 24, 2010; accepted October 19, 2010. Copyright ©2010 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182028eab Disclosure: The authors have no financial interest to declare in relation to the content of this article. www.PRSJournal.com 163S