ABSTRACT
The last three decades have witnessed enormous advances in the treatment of lower-limb ischemia from infrainguinal arteriosclerosis. In the late 1960s most patients with a threatened ischemic limb were subjected to a major amputation because they had infrainguinal arterial occlusive disease, which was deemed too difficult or risky to treat. This was particularly true of diabetic patients, who were often regarded as having such advanced distal or smallartery occlusive disease that they were categorically inoperable. Although some patients were undergoing successful aortofemoral or femoropopliteal bypasses for segmental occlusive disease of the iliac or superficial femoral arteries, many of them had only intermittent claudication. Most patients with rest pain or necrosis had complex, multilevel occlusive disease in patterns that were deemed unfavorable to treat surgically, and these patients were often subjected to primary amputation. This situation has changed dramatically in the last 20-25 years as interventional management strategies have been developed to treat virtually all patterns of arteriosclerotic disease underlying severe limb ischemia.[1] Moreover, the resulting aggressive therapeutic approach to threatening ischemia of the lower limb has proven to be effective and worthwhile.[1,2] This form of treatment has gained increasing acceptance throughout the world, even though some still question its value and cost-effectiveness.[3] Despite this residual skepticism, most vascular surgeons, most physicians, and virtually all patients acknowledge the value of the aggressive surgical and radiological approach to patients with limb-threatening ischemia. Indeed, almost all these individuals regard the advances in this field, which will be summarized in this chapter, as one of the most important positive developments that has occurred in vascular surgery in the last quarter century.
