Limb Salvage: Predictors of Major Amputation and Limb Salvage Rates in Chronic Threatening Limb Ischemia (CTLI)

Abstract

Chronic limb-threatening ischemia (CTLI) represents the most advanced and severe stage of peripheral arterial disease, with a significant clinical burden and an estimated 25% risk of major amputation within one year of diagnosis. Early identification of at-risk patients, followed by prompt and appropriate intervention, plays a crucial role in improving limb salvage outcomes. Given the high associated mortality, timely recognition and rapid revascularization remain the cornerstone strategies for preserving both limb and life.

Current outcome data highlights the seriousness of this condition, with 1-year limb salvage rates ranging from 51% to 63% and overall survival rates between 66% and 83%, while major amputations still occur in nearly 18% of patients. Although surgical bypass offers durable results, endovascular therapy is often preferred in high-risk individuals to reduce perioperative complications. Notably, outcomes are closely linked to the timing of intervention, as both excessively early and delayed revascularization have been associated with poorer results, underscoring the importance of optimal clinical judgment.

Successful management of CTLI depends on a combination of early diagnosis, aggressive risk factor modification, and a multidisciplinary treatment approach. Functional recovery after amputation is challenging, as above-knee amputees may require up to twice the normal energy expenditure for walking, making structured rehabilitation essential. Ultimately, restoring adequate vascular supply alongside comprehensive wound care is vital for achieving functional independence and improving the patient’s quality of life.

This study further identifies key predictors of major amputation, including diabetes, chronic kidney disease, hemodialysis, smoking, tissue loss, infection, severity of ischemia, and timing of revascularization. The Wound, Ischemia, and foot Infection (WIfI) classification system is utilized to stratify patients into four risk categories, ranging from very low risk (<3%) to high risk (>25%), with stage 4 indicating the greatest likelihood of amputation. This risk-based stratification allows for more targeted, timely interventions aimed at maximizing limb salvage and reducing preventable amputations.