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Chronic limb-threatening ischemia: saving the leg when ulcers or gangrene develop
Chronic limb-threatening ischemia (CLTI, critical limb ischemia) is the end stage of peripheral artery disease: perfusion of the foot is insufficient for healing, and rest pain, ischemic ulcers and necrosis develop. Without revascularization the risk of major amputation within a year remains high, so the timing of referral is decisive.
Why it develops
Atherosclerotic plaque narrows (stenosis) or completely blocks (occlusion) the arteries of the limb. Early on, blood supply is insufficient only during exertion, causing intermittent claudication. As the disease progresses, perfusion becomes inadequate even at rest: night pain in the foot appears, minor skin injuries turn into ulcers, and necrosis of the toes develops. This is CLTI.
Symptoms: foot pain at night, ulcers, gangrene
- Ischemic pain in the foot or toes at rest, mostly at night, relieved by lowering the limb
- An ulcer or wound on the foot that has not healed for more than two weeks
- Necrosis (blackening) of a toe or an area of the foot
- Pallor, cyanosis or reduced temperature of the foot, absent pedal pulses
- Diabetes mellitus combined with any of these signs
Why timing matters
Every week without adequate blood flow enlarges the zone of necrosis and raises the risk of infection. Medication and infusions do not reopen an occluded artery. The only treatment that changes the prognosis for the limb is revascularization, and the earlier it is performed, the less tissue is lost.
Sudden pain, coldness, pallor or numbness in a leg: call an ambulance (103 in Ukraine). If these signs appear or sharply worsen over minutes or hours, especially with weakness of the foot or inability to move the toes, this may be acute limb ischemia — a sudden occlusion (blockage) of an artery. Irreversible tissue damage can develop within hours (roughly six), so do not wait until morning, do not warm the leg with a heating pad or hot water, and do not rub it.
Diagnosis at the Center
Examination by a vascular surgeon, duplex ultrasound of the arteries, ankle-brachial index and toe pressure measurement and, when indicated, CT angiography. The full work-up is completed at the Center within one or two days.
Endovascular treatment
Through a puncture of the femoral or brachial artery, a guidewire is passed across the occluded segment and the lumen is restored by balloon angioplasty and, if needed, stenting. The particular challenge of CLTI is disease of the 1–3 mm arteries below the knee and in the foot: below-the-knee recanalization techniques and IVUS guidance make it possible to open the specific artery that supplies the ulcer (the angiosome principle).
The procedure is performed under local anesthesia and takes 1–3 hours; discharge is usually on day 1–2. If endovascular revascularization is not feasible, bypass and hybrid operations are performed at the Center together with the vascular surgery department. Once blood flow is restored, the ulcer is treated together with the surgeon; a minor toe amputation is performed if needed to preserve a weight-bearing foot.
Frequently asked questions
Does gangrene of a toe mean the leg will inevitably be amputated?
No. With restored blood flow, necrosis of a toe is usually managed by a minor amputation of the toe or part of it. A major amputation becomes necessary when revascularization is not possible or infection has spread through the foot, which is why delay is dangerous.
How long does the procedure take, and is it painful?
Usually 1–3 hours under local anesthesia. The patient is awake; discomfort is limited to the moment of puncture.
Is treatment possible with diabetes and chronic kidney disease?
Yes. For patients with renal failure, CO₂ angiography without iodinated contrast is used; diabetes is the most frequent comorbidity in CLTI.
What happens after discharge?
Medication to protect the result (antiplatelet agents, statins), local ulcer care, and follow-up visits with duplex ultrasound at 1, 3 and 6 months.
Book a consultation
Vascular surgeon consultation at the Shalimov Center, 30 Akademika Shalimova St, Kyiv. Booking and questions go through the contact doctor, Yurii Vahis. Patients from other cities and abroad can arrange an online consultation.
+380 44 454 20 79