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What should I know, especially if I’m a smoker or diabetic?

Do you experience a burning pain in your lower leg when you rest or lie down? This is a typical symptom of peripheral arterial disease, which occurs when the arteries that supply blood to the extremities become narrowed or blocked, reducing blood supply. In more advanced stages, the disease can cause chronic ischemic rest pain, also called critical limb ischemia, which – if left untreated – can lead to limb amputation.

• What is critical limb ischemia?

Critical limb ischemia is the most severe form of peripheral arterial disease with lesions extending to multiple vessels of the leg resulting in severely restricted blood flow to the lower leg. Low blood flow in the vessels leads to inadequate oxygen transport to the tissues and the appearance of either pain at rest (rest pain) or necrosis of the toes and heel (gangrene). Critical limb ischemia is a dangerous condition that, if not treated promptly, can lead to amputation and death.

• Do patients with diabetic foot suffer from critical lower limb ischemia?

Diabetic foot is included under the broader term of critical ischemia and is the result of the simultaneous occurrence of multiple consequences of diabetes: vascular occlusion, peripheral neuropathy, osteomyelitis, ulceration and arthropathy. It is important to note that 1 in 4 patients with diabetes will develop a diabetic ulcer during their lifetime. If not treated in time, 50% of ulcers will become infected and 20% of these will result in amputation. It is estimated that over one million amputations are performed on diabetics worldwide each year, which corresponds to 1 amputation every 20 seconds somewhere in the world.

• What other risk factors can lead to critical lower limb ischemia?

The main risk factor for the occurrence of critical lower limb ischemia in non-diabetics is smoking. Other risk factors are chronic cortisone use, renal failure, high cholesterol, obesity and metabolic syndrome, among others. Finally, it is worth noting that the use of electronic cigarettes is also responsible for the occurrence of peripheral arterial disease.

• How should a patient with critical lower limb ischemia be approached?

Critical lower limb ischemia is a complex condition that must be approached by a specialized team of doctors with the vascular surgeon as the main orchestrator. In case of ischemia, an immediate attempt to revascularize the lower limb is necessary. It is very important to emphasize that no leg amputation should be performed without prior diagnostic digital angiography demonstrating that improvement in blood flow cannot occur.

• What do new endovascular techniques offer in the treatment of the condition?

The great technical difficulty in patients with critical lower limb ischemia is that patients present with occlusions in multiple small or medium-sized vessels and traversing these occlusions can be particularly challenging. New endovascular techniques (reverse puncture, use of reentry devices, use of special wires and support catheters) allow the successful opening of these vessels from the knee to the toes.

Maintaining vascular patency is achieved either:

(1) by using a balloon or stent at the site of the lesion, or

(2) by using a special device to remove the plaque (atherotome) and coat the surface of the vessels with a special drug.

Recent studies using these methods in specialized centers in America and Europe have shown that their use dramatically reduced amputations and indirectly extended the life span of patients with critical lower limb ischemia. Many of these new techniques were applied for the first time in Greece by our team at the ultra-modern “Prometheus” Hybrid Surgery Center of the Athens Medical Center.

• What does Hybrid surgery offer to patients with critical lower limb ischemia?

Hybrid surgery offers unique imaging capabilities that are very important especially in small vessels. In addition, special artificial intelligence programs uniquely assist the vascular surgeon during the operation and increase its safety. In cases where the endovascular approach is not successful or the vascular surgeon initially estimates that it will not be feasible (especially more extensive damage, especially calcified vessels, etc.), then Hybrid surgery offers unique asepsis for performing an open surgical bypass.

When there is no solution other than amputation: The technique of converting veins into arteries

In extremely severe cases where either the patient comes to the vascular surgeon in an advanced stage of gangrene or the condition of the arteries of the lower limb does not bring further improvement, there is the possibility of reperfusion of the lower limb through the conversion of the veins of the leg into arteries. This procedure is complex and is performed in selected centers throughout Europe, including by our team at the Athens Medical Center.