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Chronic limb-threatening ischemia, successful infra popliteal endovascular revascularization: a case report

  • Dawar Sitaba Kleruk ,
  • Yopie Afriandi Habibie ,


Introduction: Chronic limb-threatening ischemia (CLTI), a manifestation of peripheral arterial disease (PAD) that is characterized by chronic ischemic pain in the foot, inadequate tissue perfusion at rest more than 2 weeks, non-healing wounds, or gangrene that is attributable to objectively proven arterial occlusive disease. Endovascular surgery has played an important rules for revascularization in limb saving.

Case description: 57-years-old man came to the Zainoel Abidin General Hospital emergency room, with a chief complaint of ischemic pain at the right foot since 3 months ago, and being extremely progressive for 10 days. He has no history of smoking and 10-year history of controlled type 2 diabetes mellitus. On the physical examination revealed a stable hemodynamic, an unhealed wound in the right lower limb as well as an open wound size 10cm x 6cm x 4cm. He has palpable femoral pulses but not distal pulses. Peripheral CT angiography obtained a total occlusion at the right anterior tibialis artery (ATA), and no flows at the right dorsalis pedis artery (DPA). Performed a revascularization procedure with endovascular therapy using 3 mm balloon angioplasty with good results along the ATA and DPA. The patient was discharged on the 4th day after surgery. Clinical Evaluation after 2 months showed improvement on pain, good ulcer healing and ready for skin grafting.

Conclusion: The goal of treatment for CLTI is to relieve pain, heal wounds, and preserve a functional limb, with a cornerstone of treatment is timely arterial revascularization Endovascular surgery in one of the best revascularization techniques for CLTI.


  1. Norgren, L, Hiatt, WR, Dormandy, JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007; 33(suppl 1):S1–S75. doi: 10.1016/j.jvs.2006.12. 037.
  2. Salman AA. Endovascular therapy for critical limb ischemia. Vascular Medicine 2008;13:267–279.
  3. Farber A. Chronic Limb Threatening Ischemia. The New England Journal of Medicine. Massachusetts Medical Society. N Engl J Med. 2018; 379:171-180 DOI: 10.1056/NEJMcp1709326
  4. Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH; GVG Writing Group. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019;69(6S):3S-125S.e40. doi: 10.1016/j.jvs.2019.02.016.
  5. Anhar A, Habibie YA. Revascularization Limb Salvage in Chronic Limb Threatening Ischemia: Does Open Surgery Still The Best Option in The Era of Endovascular Therapy: Case Report. Intisari Sains Medis. 2020;11(1):369-372. doi: 10.15562/ism.v11i1.745
  6. Scott K. Management of Critical Limb Ischemia, Circ Cardiovasc Interv. 2016;9:e001946. DOI: 10.1161/ CIRCINTERVENTIONS.115.001946.
  7. Thukkani AK, Kinlay S. Endovascular intervention for peripheral artery disease. Circ Res. 2015;116:1599–1613. doi: 10.1161/CIRCRESAHA.116.303503.
  8. Luigi U. Critical limb ischemia: current challenges and future prospects. Vascular Health and Risk Management. 2018:14:63–74. doi: 10.2147/VHRM.S125065.
  9. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol. 2006;47:1239–312.
  10. Goodney PP, Travis LL, Nallamothu BK, et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes 2012;5:94–102. doi: 10.1161/CIRCOUTCOMES.111.962233.
  11. Mills JL Sr, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, Andros G; Society for Vascular Surgery Lower Extremity Guidelines Committee. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014;59(1):220-34.e1-2. doi: 10.1016/j.jvs.2013.08.003.
  12. Syed MH, Zamzam A, Valencia J, Khan H, Jain S, Singh KK, Abdin R, Qadura M. MicroRNA Profile of Patients with Chronic Limb-Threatening Ischemia. Diagnostics. 2020; 10(4):230.
  13. Kim TI, Vartanian SS, Schneider PA. A Review and Proposed Classification System for the No-Option Patient with Chronic Limb-Threatening Ischemia. Journal of Endovascular Therapy. 2020. doi: 10.1177/1526602820963911.
  14. Stella J, Engelbertz C, Gebauer K, Hassu J, Meyborg M, Freisinger E, Malyar NM. The outcome of patients with chronic limb-threatening ischemia with and without revascularization. Vasa. 2020;49(2):121-127. doi: 10.1024/0301-1526/a000831.
  15. Nomura T, Tasaka S, Ono K, Sakaue Y, Wada N, Keira N, Tatsumi T. Successful limb salvage by endovascular treatment for critical limb ischemia subsequent to acute limb ischemia. Oxf Med Case Reports. 2019;2019(10):omz103. doi: 10.1093/omcr/omz103.
  16. Diaz-Sandova L. Critical Limb Threatening Ischemia: The Time has Come for a Multidisciplinary Approach. Journal of Vascular and Endovascular Therapy. 2019;4(1):26-32.
  17. Iida O, et al. Worse limb prognosis for indirect versus direct endovascular revascularization only in patients with critical limb ischemia complicated with wound infection and diabetes mellitus. Eur J Vasc Endovasc Surg 2013;46:575–82.
  18. Raghu Motaganahalli, et al., Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Ischemia trial (BEST-CLI), Vascular & Endovascular Review 2020;3:e05.

How to Cite

Kleruk, D. S., & Habibie, Y. A. (2021). Chronic limb-threatening ischemia, successful infra popliteal endovascular revascularization: a case report. Bali Medical Journal, 10(2), 692–695.




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Dawar Sitaba Kleruk
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Yopie Afriandi Habibie
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