Is revascularization and limb salvage always the treatment for critical limb ischemia?

Despite marked advances in the technical ability to perform lower extremity revascularization, the decision whether to perform primary amputation or attempt revascularization in high risk patients is a major part of modern vascular care. With an aging population and improved medical care that has increased life expectancy, more patients with severe systemic disease are presenting with critical limb ischemia (CLI). In addition, it is well recognized that CLI patients suffer diagnostic delays and poor risk factor modification, which in part contributes to limb loss and poor patient survival. Unlike other disease entities, CLI does not have a clear clinical pattern that provides consistent entry to medical care and uniform treatment algorithm. In this commentary we will discuss the issue from several viewpoints. The unique features of the antecedent natural history of CLI will be presented. Available data on functional outcomes on both therapies for CLI will be presented. Morbidity and mortality of both approaches will be covered, including the risk of multiple procedures, followed by an examination of specific problematic patient populations. Finally, we will close with some potential approaches to these problems and future studies that are needed to push forward our ability to appropriately make these difficult decisions for an increasingly aging population.