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The Surgical Choice for Treatment of Critical Limbs Ischemia (pp.195-210) $100.00
Authors:  (G.Carella, F. Stilo, M.Giardina, P. Spada, M. Bordoni, F. Spinelli, A. David, I.R.C.C.S. Humanitas Hospital Milan, Italy, and others)
The treatment of critical ischemia can be performed by various therapeutic approaches including medical therapy, endovascular or surgical treatment. All treatments however, must be associated with an aggressive modification of cardiovascular risk factors.
For the overwhelming majority of patients with CLI, revascularization represents the best option. The choice of treatment has been widely debated and depends on the patient's clinical condition, degree of ischemia, the location of atherosclerotic lesions and also the expertise and experience of the treatment centre.
On the basis of recommendations contained within the Trans-Atlantic Inter-Society, Consensus Document on Management of Peripheral Arterial Disease 2007 (TASC II)(2), the morphological indications for bypass grafts are represented principally by TASC D patients: chronic total occlusion of common femoral artery (CFA) or superficial femoral artery (> 20 cm involving the poplietal artery), and chronic total occlusion of the popliteal artery and proximal trifurcation vessel.
This classification considers the morphological lesions of the vascular bed, in an attempt to direct the choice of surgical or endovascular treatment, based on the length and number of stenosis/occlusions. However this classification did not entail the clinical status of the patients which may also influence results and healing (3).
The superficial femoral and popliteal arteries are more often affected in patients with diabetes than is the aortoiliac segment, so when claudication is present, it is usually experienced in the calf. Diabetic patients with foot ulcers and gangrene are often found to have a strong popliteal pulse and absent pedal pulse. This finding is due to a highly prevalent pattern of predominantly tibial artery occlusive disease in diabetics. In most cases the peroneal artery is patent and is the last of the three crural arteries to occlude. The primary pedal arch is almost always incomplete, but in most cases, at least a segment of the plantar
arch retains patency, if not continuity, with the anterior and posterior circulation. Consequently, by-pass to a single tibial or peroneal artery usually provides good blood flow to the foot, resulting in a high likelihood that the patient is a suitable candidate for revascularization (4). In this case of very poor run-off, bypass to the “isolated segment” is the preferential option with a reasonable success rate (5-7). 

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The Surgical Choice for Treatment of Critical Limbs Ischemia (pp.195-210)