What Is the Goal of CLI Therapy? Arterial Patency vs. Wound Healing vs. Limb Salvage

On the first day of AMP 2024, Yolanda Bryce, MD, RPVI, from Memorial Sloan Kettering Cancer Center in New York, spoke about the complex goals of critical limb ischemia (CLI) therapy, emphasizing the nuanced balance between achieving arterial patency, wound healing, and limb salvage. Dr. Bryce used a clinical case of a 74-year-old man with multiple comorbidities, including hepatitis C, cirrhosis, and a history of lung cancer, to illustrate the challenges and objectives of CLI treatment. The patient presented with right lower extremity rest pain and necrotic toes. Despite successful revascularization and improved arterial patency, the patient exhibited poor wound healing and noncompliance with follow-up care, leading to ongoing challenges in limb salvage and overall management.

Dr. Bryce spoke about the importance of defining goals in CLI therapy. These goals include: 

• Arterial patency: Achieving and maintaining arterial patency is critical for re-establishing blood flow. However, it primarily measures the technical success of the surgeon/proceduralist and may not directly correlate with patient-centered outcomes.
• Wound healing: This goal is more patient-centered, focusing on reducing wound size, preventing infections, and promoting overall healing, which directly influences limb salvage.
• Limb salvage: Beyond avoiding major amputations, limb salvage includes improving functional status and mobility, which significantly impacts the patient's quality of life.
• Prolonged survival: This broader goal encompasses managing comorbid conditions, preventing major cardiovascular events, and ensuring long-term survival, which requires a multidisciplinary approach.

She then discussed measurement and outcome assessment for these goals: 

• Arterial patency: Measured through duplex ultrasound, angiography, ABI, and TcPO2, focusing on patency rates and incidence of restenosis.
• Wound healing: Evaluated using wound measurement tools, photography, and healing rates, with outcomes measured by reduction in wound size, time to closure, and tissue quality.
• Limb salvage: Assessed by tracking amputation rates, functional status, and patient-reported outcomes, with a focus on mobility and quality of life.
• Prolonged survival: Monitored through survival analysis, cardiovascular event tracking, and health assessments, with survival rates and event incidence as key outcomes.

Dr. Bryce highlighted that the goals of CLI therapy should be patient-centered, integrating arterial patency, wound healing, and limb salvage into a holistic approach that prioritizes the patient's overall well-being and long-term survival. She underscored the importance of individualized care plans and multidisciplinary collaboration to achieve the best outcomes for patients with CLI.