Treatment modalities for chronic limb-threatening ischemia: strategies and outcomes

Chronic limb-threatening ischemia (CLTI) is a serious condition in which there is inadequate blood flow to the foot due to calcification of the vessels causing rest pain or unhealing wounds. Treatment by endovascular revascularization is preferred because of the minimally invasive technique. However, endovascular revascularization for the treatment of CLTI can be difficult due to the severity of the calcification and extensiveness of the disease in the below-the-knee arteries.This thesis exists of 3 parts: (1) outpatient care of CLTI patients, (2) balloon angioplasty techniques for the treatment of below-the-knee lesions and (3) the evaluation of the percutaneous deep venous arterialization (pDVA) technique in no-option CLTI patients.For the outpatient care, a multidisciplinary approach remains essential for the treatment of a diabetic foot ulcer. The benefits of antibiotic treatment for clinically uninfected foot ulcer should be further explored. Treatment of infrapopliteal lesions with drug coated balloons has not (yet) proven its benefits over treatment with plain old balloons. For the treatment of highly calcified and long lesions, high-pressure, noncompliant balloons have shown to be safe and feasible. An ex-vivo flow model was validated to study the effects of endovascular treatments on the arterial wall in a standardized, physiological environment, limiting the need for laboratory animal testing. Final, the pDVA technique, its outcomes and postprocedural follow-up care was evaluated in this thesis. Key elements are the acknowledgment that the DVA needs 6 weeks to develop, and the need for a multimodal approach including surveillance, wound care, and a staged amputation strategy