The current
issue of Jornal Vascular Brasileiro publishes three original articles
on chronic critical limb ischemia (CCLI).1-3
The first article shows the profile of patients affected by this severe
disorder, and the other two focus on revascularization-based treatment.
The present-day
definition established by the Transatlantic Inter-Society Consensus
(TASC) regards patients with chronic ischemic rest pain, ulcerations
or gangrene resulting from arterial occlusive disease that is objectively
confirmed, as CCLI carriers. As a consequence, it includes patients
in which major amputation is necessary within six months, unless hemodynamics
is improved.4
Actually,
about 90% of CCLI carriers necessitate surgical treatment (revascularization
or amputation) within one year after the onset of symptoms.5
CCLI often affects old patients with multiple comorbidities. Life
expectancy is limited, with mortality rates estimated at 20% a year.
There is only one positive effect on survival rate: extremities save!
A major amputation is the common denominator of the worst prognosis.6
Arterial surgery, which now celebrates fifty years and distal revascularizations,
which have recently come to full maturity, are the most commonly required
procedures in our area. During the first decades of arterial surgery
for the treatment of ischemia in industrialized countries, the rate
of amputations were not reduced as expected. Only in the last 15 years
the rate of major amputations has decreased, especially because of
the widespread use of distal shunts.5,6
The most
important determining factor for survival is the patient's quality
of life. Old persons affected by CCLI should not be denied the benefits
of revascularization for maintenance of the extremity, provided they
have adequate clinical conditions.7,8
In my
tender years as a vascular surgeon, revascularizing distally to the
popliteal artery was unacceptable, and angiographic studies were limited
to the calf region. The widespread use of Doppler ultrasound, which
reveals the maintenance of patent distal vessels that are amenable
to revascularization even when all proximal trunks are occluded, allowed
the angiographic technique to be improved, showing the circulatory
tree of the foot. The improvement produced by microsurgery enabled
vascular surgeons to broaden their horizons and explore the small
arteries of the foot. The acceptance of distal revascularization and
its widespread use revolutionized the salvage of limbs that were threatened
by amputation due to imminent or evident gangrene.7,8
The articles
published in the current issue of J Vasc Br attest to technical excellence
and confirm the maturity reached by vascular surgery.
1.
Silvany Neto AM, Nunes JLB, Araújo F° JS, et al. Doença
arterial oclusiva periférica de membros inferiores em hospitais
públicos de Salvador - perfil dos pacientes e do atendimento.
J Vasc Br 2002;1(3):201-6.
2.
Vieira de Mello A, dos Santos CMT, Oliveira BC, Vieira de Mello
R. Revascularização distal dos membros inferiores:
experiência de 13 anos. J Vasc Br 2002;1(3):181-92.
3.
Frankini AD, Pezzella MVC. Revascularização no pé
em paciente com isquemia crítica. J Vasc Br 2002;1(3):193-201.
4.
TransAtlantic Inter-Society Consensus (TASC). Management of peripheral
arterial disease - Chronic Critical Limb Ischemia. Intl Angiology
2000;19:183-304.
5.
Pell J, Boyd A. The impact of arterial reconstructive surgery on
major amputation. Critical Ischaemia 1999;9:29-32.
6.
Norgren L. Do age and treatment results affect outcome for critical
limb ischaemia interventions? Critical Ischaemia 1998;8:66-7.
7.
von Ristow A, Cury JM. Aterosclerose obliterante periférica
- tratamento cirúrgico das lesões abaixo do ligamento
inguinal. In: Maffei FHA, editor. Doenças vasculares periféricas.
Rio de Janeiro: MEDSI; 2002. p. 1071-1106.
8.
von Ristow A, Cury JM, Pedron C, Vescovi A. Obstruções
arteriais crônicas infra-inguinais- Tratamento cirúrgico.
In: Brito CJM, editor. Cirurgia vascular. Rio de Janeiro: Revinter;
2002. p. 589-658.
