Chronic lower extremity ischemia due to peripheral arterial disease (PAD) is the most common cause of walking disability seen by vascular specialists. The manifestations of chronic lower extremity ischemia often include pain produced by varying degrees of ischemia, ranging from   exertional muscular pain In the calf and foot muscles (intermittent claudication) to ischemic rest pain.

The symptoms of intermittent claudication are alleviated by a brief period of rest, after which the patient can resume walking. Popliteal and tibial artery occlusions are more commonly associated with limb-threatening ischemia, owing to the paucity of collateral vascular pathways beyond these lesions.

Critical Limb Ischemia

Critical limb ischemia (CLI) is the most severe form of PAD and represents approximately 1% of the total number of patients with PAD. The common major manifestations of CLI are rest pain and ischemic ulceration or gangrene of the forefoot or toes, representing a reduction in distal tissue perfusion below resting metabolic requirements. Rest pain is usually described as a burning sensation or as an uncomfortable coldness or paresthesia of sufficient intensity to interfere with sleep.

More than 50% of diabetic foot ulcers are of ischemic or neuroischemic origin. ischemia needs to be excluded in all ulcers, since PAD is the most important limiting factor for healing of ischemic or neuroischemic diabetic foot ulcers. Progression to gangrene occurs in 40% of patients with DM, compared with only 9% in nondiabetic patients with CLI.

 Revascularization is recommended only in cases of severe claudication, and only after medical therapy has failed. when it is anatomically feasible, endovascular therapy is generally preferred to open surgery for most cases of claudication.

Endovascular treatment offers low morbidity and mortality associated with a procedure that is usually performed on an outpatient basis.

For Patients with CLI, five objective criteria—angiographic pattern of disease, presenting complaints, functional status of the patient, medical comorbidities, and technical factors—to recommend the most appropriate interventional therapy (angioplasty, open surgery, or major limb amputation).

Endovascular treatment is often the first option for treating infrainguinal peripheral arterial disease (PAD). Endovascular therapy is frequently chosen because of lower rates of perioperative morbidity and mortality.

Percutaneous transluminal angioplasty (PTA) with adjunctive stenting is an increasingly used and accepted technology, and it is the technique most frequently employed for infrainguinal endovascular treatment.

The diseased arterial segment is subsequently balloon-dilatated in the subintimal plane to achieve revascularization. Stenting is an adjunctive procedure used either routinely or selectively for the treatment of complex lesions or persistent stenosis or to correct intraprocedural complications. Recently, drug-eluting stents (DES) have been designed that release antiproliferative drugs after implantation.