Extensive Revascularization or Primary Amputation: Which Patients with Critical Limb Ischemia Should Not Be Revascularized?

The commitment of vascular specialists to preserve the lower extremity has pushed the limits of revascularization. It is not uncommon for patients with severe distal disease to undergo extensive vascular reconstruction, bringing a bypass graft down to the ankle and beyond. Such procedures, when well-planned and well-executed, can result in a preserved and fully functional lower extremity with complete healing of all necrotic tissue. As noted in the guidelines presented by the TransAtlantic Inter-Society Consensus Working Group, there are patients who will benefit from primary amputation rather than extensive revascularization. Patients who are unable to tolerate the planned procedure or unlikely to have a functional extremity despite restoration of distal flow, should be considered for major amputation that eliminates the source of rest pain and all necrotic tissue. Although morbidity and mortality of major amputation continues to be significant, advances in prosthetic development and amputation technique can lead to preserved ambulatory ability and improved quality of life.