A 55-year-old diabetic woman presents with rest pain and gangrene of the right second toe (Rutherford Category 5 CLI). Duplex Doppler shows tibial vessel disease. ABI is 0.45. The most appropriate first-line intervention according to TASC II and GVG guidelines is:

• A Below-knee amputation
• B Medical therapy with cilostazol alone
• C Revascularization (endovascular angioplasty or bypass) prior to amputation ✓
• D Hyperbaric oxygen therapy

Explanation

Critical limb ischemia (CLI, Rutherford 4–6) carries a 1-year amputation risk of 30–40% without intervention. Revascularization — either endovascular (balloon angioplasty ± stenting) for short-segment disease or open bypass (femoro-popliteal, tibial) for diffuse disease — is the gold standard to achieve limb salvage. The BASIL trial supports bypass as durable for tibial CLI. Amputation is considered only when revascularization is anatomically impossible or patient fitness precludes intervention. Cilostazol is used for claudication (Rutherford 2–3), not CLI.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.