Chronic limb-threatening ischaemia

Aboyans, 2018Gerhard-Herman, 2017

Chronic limb-threatening ischaemia is the most severe type of lower-limb peripheral artery disease (PAD) and is characterised by pain at rest, extensive necrosis (gangrene) or lower-limb ulceration of longer than 2 weeks duration. Chronic limb-threatening ischaemia frequently progresses and has a high risk of tissue loss unless revascularisation is performedAboyans, 2018.

Refer all patients with chronic limb-threatening ischaemia to a vascular specialist for early consideration of angiography and revascularisation.

Vascular reconstruction (eg bypass grafting, endarterectomy, endoluminal techniques) is the treatment of choice. Revascularisation may not be possible because of the extent and distal nature of the PAD, and a primary amputation may be the only way to control complications and painJaff, 2015.

No medical therapies improve limb outcomes in chronic limb-threatening ischaemia.

Pain associated with chronic limb-threatening ischaemia is often severe, and opioids may be required. Pressure area care and pressure off-loading bandages are important. Elevating the head of the bed may reduce the severity of nocturnal rest pain.

Maintain high to normal systolic blood pressure (BP) to assist tissue perfusion. This may involve reducing the dose of a BP-lowering drug in patients with pre-existing elevated BP. Consider gradual withdrawal of beta-blocker therapy, unless the benefit of beta-blocker therapy outweighs the potential for harm.

Signs of sepsis are masked by poor circulation. If infection is present, prescribe antibiotics according to the results of culture and susceptibility testing; see Directed therapy for bloodstream infections, including sepsis and septic shock for regimens.

Patients with chronic limb-threatening ischaemia who are admitted to hospital have an increased risk of venous thromboembolism (VTE), particularly if they are immobile. Use VTE prophylaxis as in Examples of VTE prophylaxis for nonsurgical patients in hospital. Do not use graduated compression stockings or pneumatic compression devices for patients with chronic limb-threatening ischaemia.