TREATMENT OF CRITICAL LIMB ISCHEMIA IN THE ELDERLY

Acute critical limb ischemia (CLI) is a rather frequent clinical event in elderly patients. Atherosclerotic plaques or cardiopathies (atrial enlargement and fibrillation, ventricular thrombosis) are the most fr equent clinical situations related to peripheral embolization. Rapid d iagnosis followed by suitable treatment allows us to obtain good resul ts even in elderly patients. The decision about the treatment of acute CLI is related to the clinical and functional condition of the patien t. Anamnesis must inquire about recent ischemic or hemorrhagic events in the cardiovascular, gastro-intestinal and urinary apparatuses, or t he presence of disorders of coagulation and fibrinolysis. An objective clinical examination and a multidimensional assessment must evaluate the degree of functional impairment and provide the basis of a therape utic strategy (cost/benefit ratio). Diagnostic examination in the frai l elderly patient (FP) involves only the ultrasonographic method, to l ocalize the level of thromboembolic occlusion, which is followed by an giography in the non-frail patient (NFP). In the case of proximal occl usion (of the iliac or femoro-popliteal arteries), the elective treatm ent in both groups of patients is thromboendarterectomy. plus transcut aneous angioplastics or by-pass in NFP, followed by prostacyclin or he parin infusions. Distal occlusion (below the popliteal artery) in FP i s treated only with prostacyclin or heparin, whereas, in NFP, fibrinol ysis is the elective treatment, followed by prostacyclin or heparin. I n the cases of distal gangrene, before amputation is performed, a ''li mb salvage'' operation must be considered. After the acute phase of me dical or surgical treatment, vasoactive or antiplatelet, drugs are emp loyed in FP, whereas in NFP the use of coumadin is the preferred treat ment to counteract the re-thrombosis and prevent new embolizations. An tiplatelet therapy could be selected when coumadin is contra-indicated .