Lin Jaime H X, Papanas Nikolaos, Zayed Hany, Vas Prashanth R J
Diabetes and Diabetic Foot, King's College NHS Foundation Trust, London, UK.
Department of Medicine, Woodlands Health, Singapore.
Int J Low Extrem Wounds. 2025 Mar;24(1):7-11. doi: 10.1177/15347346231188874. Epub 2023 Jul 18.
Chronic limb-threatening ischaemia (CLTI) is a severe form of peripheral arterial disease (PAD) and is associated with an increased risk of amputation, mortality, and significantly impaired quality of life. International guidelines recommend considering timely revascularisation and optimal medical therapy to improve limb perfusion in individuals with CLTI. The 2 primary revascularization approaches for CLTI are open bypass surgery (BS) and endovascular therapy (EV), however, there is currently no consensus on the best initial treatment strategy for CLTI, leading to uncertainty among clinicians. To shed light on this issue, 2 recent trials, namely best endovascular versus best surgical therapy in patients with CLI (BEST-CLI) and bypass versus angioplasty for severe ischaemia of the leg (BASIL-2), have tried to provide valuable insights. While a definitive conclusion on the optimal revascularisation approach is still pending, these trials offer immediate and clinically relevant information to the diabetic foot multidisciplinary team. The trials encompassed a distinct range of patient cohorts and included participants with varying degrees of medical and physical frailty. Taken together, their findings, highlight the need for an individualised revascularisation strategy which accounts for underlying comorbidities, risk factors, disease severity, availability of suitable bypass conduits, surgical risks, and timely access to procedures. Regardless of the chosen strategy, early referral of patients with diabetes and CLTI to a specialist team within a multidisciplinary environment is crucial. Comprehensive care should encompass essential elements such as adequate debridement, infection control, offloading, glycaemic control, smoking cessation, and patient education. By addressing these aspects, healthcare providers can optimise the management and outcomes for individuals with CLTI and diabetes.
慢性肢体威胁性缺血（CLTI）是外周动脉疾病（PAD）的一种严重形式，与截肢、死亡风险增加以及生活质量显著受损相关。国际指南建议考虑及时进行血运重建和优化药物治疗，以改善CLTI患者的肢体灌注。CLTI的两种主要血运重建方法是开放旁路手术（BS）和血管内治疗（EV），然而，目前对于CLTI的最佳初始治疗策略尚无共识，这导致临床医生存在不确定性。为了阐明这个问题，最近的两项试验，即CLI患者最佳血管内治疗与最佳手术治疗（BEST-CLI）以及腿部严重缺血的旁路手术与血管成形术（BASIL-2），试图提供有价值的见解。虽然关于最佳血运重建方法的明确结论仍未得出，但这些试验为糖尿病足多学科团队提供了即时且与临床相关的信息。这些试验涵盖了不同范围的患者队列，包括具有不同程度医疗和身体虚弱的参与者。综合来看，他们的研究结果强调了需要一种个性化的血运重建策略，该策略要考虑潜在的合并症、风险因素、疾病严重程度、合适旁路管道的可用性、手术风险以及及时获得手术治疗的机会。无论选择何种策略，在多学科环境中将糖尿病和CLTI患者尽早转诊至专科团队至关重要。全面的护理应包括充分清创、感染控制、减负、血糖控制、戒烟和患者教育等基本要素。通过关注这些方面，医疗服务提供者可以优化CLTI和糖尿病患者的管理及治疗效果。
