Changing the Present Algorithm of Evaluation and Therapy of Chronic Limb-Threatening Ischemia
© 2025 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Vascular Disease Management or HMP Global, their employees, and affiliates.
VASCULAR DISEASE MANAGEMENT. 2025;22(11):E99
Hello and welcome to the November issue of Vascular Disease Management.
In this issue there is a landmark article that should be required reading for all providers caring for patients presenting with peripheral arterial disease (PAD), particularly those presenting with chronic limb-threatening ischemia (CLTI). The article is entitled “Chronic Limb-Threatening Ischemia: Are We Saving Limbs but Losing Lives”? (To see a video of Dr Walker's commentary, click here.)
The authors are distinguished vascular surgeons Christopher Zarins, MD, and Dainis Krievins, MD, who are appropriately challenging what has been the standard of care for patients presenting with CLTI.
The article points out that we are clearly saving more limbs with limb revascularization but have failed to improve mortality, with reported rates of 1-year mortality at 20%, and 70% mortality at 5 years.
The article cites that more than 50% of deaths are due to ischemic heart disease. The authors note that the conventional standard of care in patients without symptoms is to proceed with limb revascularization without evaluation of myocardial ischemia. Studies have shown that with modern surgery and anesthesia there was no difference in operative mortality demonstrated with cardiac evaluation prior to surgery.
The authors of this article agree that operative mortality is not increased without assessment of coronary artery disease but argue that we should evaluate patients presenting with CLTI for underlying coronary artery disease with its subsequent mortality risk if we are to improve future outcomes post-revascularization.
The authors appropriately point out that many patients with CLTI lack typical anginal symptoms but may have anginal equivalents. It is noted that patients with CLTI and those with claudication often cannot exercise enough to reach an anginal threshold.
I would like to add that many of these patients are diabetic and may have faulty anginal warning symptoms.
The authors point out that guideline-directed medical therapy (GDMT) should be instituted as primary prevention, but this has not resulted in adequate mortality reduction.
The authors propose a new algorithm utilizing coronary CTA with FFRCT to identify coronary artery obstructive disease that is associated with ischemia to identify patients at increased risk of later cardiac events.
A single-center study is cited demonstrating that utilizing this strategy there was a dramatic reduction in subsequent cardiac events and mortality at 2-year and 3-year follow-up periods. In this study, this evaluation did not delay the leg revascularization procedures, but it did decrease the time to appropriate myocardial revascularization in those at risk. This study appropriately points out that PAD is often associated with systemic atherosclerotic disease, which remains the leading cause of death in the United States and much of the world.
I think that it is possible to achieve significant mortality reduction with earlier detection of even asymptomatic PAD if there is evidence of concomitant coronary disease. This may allow earlier implementation of GDMT to lessen the risk of atherosclerotic disease progression.
When the diagnosis of PAD is made, we have identified a patient at significantly higher long-term cardiovascular risk. PAD requires evaluation of more than just the legs. I firmly believe that “sick legs are almost never attached to healthy individuals”.
We must change our present algorithm of evaluation and therapy. We have succeeded in saving limbs but have failed to ideally improve mortality statistics with present treatment algorithms. n
