Patients with critical limb ischemia (CLI) not suitable for revascularization: the “dark side” of CLI

Abstract

Critical limb ischemia (CLI) is the most advanced stage of peripheral arterial disease (PAD). Its prognosis is poor, with high rates of limb amputation and cardiovascular mortality. The international guidelines consider limb revascularization as the first line of the treatment strategy for CLI. However, despite the progress of revascularization techniques, many patients with CLI are still considered not suitable for these procedures and treated with conservative limb treatments. We have consulted the most important guidelines on PAD and CLI published over the past two decades focusing on the epidemiology, treatment, and outcomes of CLI patients not suitable for revascularization. Our review shows that only the TASC guidelines report 25% of CLI patients conservatively treated. Regarding the treatments, all the guidelines agree that the conservative treatment is based on the best medical management of cardiovascular risk factors associated with pain drugs and wound management. Other treatments such as prostanoids, spinal cord stimulation, vasodilators, or angiogenic therapies have shown uncertain positive outcomes in reducing limb amputation and mortality. In conclusion, this work outlines the scarce consideration that the guidelines have had about these patients over the past two decades. However, this review tries to draw the main novelties and possible future treatments for the better management of this group of patients still resident in the “dark side” of the CLI.