Revaskularisation und amputation bei kritischer ischämie

The worldwide high incidence of major amputations has prompted demands for a concept for improved treatment strategies to reduce the rate of major amputations. More than 90% of major amputations are due to vascular disease and diabetes. The importance of acute and especially of chronic critical limb ischemia is often underestimated and the data on morbidity and mortality are compelling. Vascular centers of excellence have in the last decades shown the possibility to reduce the rate of amputation by aggressive revascularization modalities. Their efforts are justified by high rates of patency and limb salvage. However, the emphasis should also be placed on clinical outcome, such as healing of chronic wounds, survival without an amputation and quality of life. In this article clinical signs, methods of diagnostic and therapeutic pathways in critical chronic limb ischemia and vascular diseases of diabetics are discussed. The decision whether to reconstruct or to amputate will be discussed. The decision is always specific for each patient taking different risk factors of comorbidities into consideration. Several studies have observed that successful revascularization results in an immediate and lasting improvement in quality of life. Major amputation could, however, be necessary and indicated when there is overwhelming infection that threatens the patient's life, when extensive necrosis has destroyed the foot and in bed-ridden elderly patients with flexion contractures and rest pain which cannot be controlled. Age alone is not a contra-indication for arterial reconstruction.