Management of critical limb ischemia in the patient with diabetes

Management of peripheral artery disease (PAD) and critical limb ischemia (CLI) in the patient with diabetes is an ever-important challenge for the vascular specialist. Patients with diabetes and CLI represent a unique subset - due to the different etiology, clinical presentation and outcomes compared to patients with CLI but no diabetes - and are at a high risk for the development of diabetic foot ulceration. The presence of PAD in a patient with diabetic foot ulceration is in turn associated with much poorer outcomes, including failure to heal wounds and, ultimately, increased risk of limb loss, as well as increased overall cardiovascular mortality. There remains a paucity of robust evidence as to the appropriate first-line method of revascularization in a patient with diabetes and CLI, however the clinical outcomes (following endovascular or open surgery) appear broadly similar and the decision of whether, when and how to revascularize should therefore be taken on an individual patient basis, in the context of a multi-disciplinary team. However, revascularization is only one part of the treatment of a patient with diabetes and ulceration and the outcomes of successful revascularization are not always predictable. The presence of infection, edema and neuropathy may also contribute to reduced perfusion and poor oxygenation and these factors should be addressed concurrently, along with aggressive medical management of cardiovascular risk factors.