Chronic critical limb ischemia (CLI) is the most severe clinical manifestation of lower limb peripheral arterial disease (PAD). According to the definition from the TransAtlantic Consensus Document, CLI is diagnosed in presence of rest pain and/or ulceration and gangrene of the foot associated with objective demonstration of critical arterial insufficiency, as evidenced by reduced ankle-brachial index, or toe-brachial index, or transcutaneous oximetry. The fate of the limb suffering from CLI is often to undergo major amputation if a revascularization procedure is not performed.

Diabetes mellitus is a risk factor for PAD development. The coexistence of PAD and peripheral neuropathy predisposes to the formation of foot ulcer. For this reason, a large proportion of patients with CLI are diabetic. Indeed, in diabetic subjects there is a consistently increased risk of major amputation, and diabetes mellitus is present in the majority of non-traumatic cases of limb loss.

To avoid major amputation, in case of CLI a revascularization procedure should be attempted. Several Authors reported their experience with classic open surgery, mainly consisting of femoro-popliteal or femoro-distal bypass. Given the cardiovascular comorbidity affecting these subjects, a less invasive approach is preferable.

Percutaneous transluminal angioplasty (PTA), with or without the use of endovascular protheses (stents), is a safe and effective therapy for PAD. However, this minimally invasive approach might be technically challenging in patients with diabetes mellitus, because of the particular features of diabetic macroangiopathy. In patients with diabetes mellitus, the arteries involved by the obstructive process are often the very distal ones, including crural and foot vessels. The most frequent angiographic finding in diabetic patients with CLI is very long calcified occlusion of infrapopliteal arteries.

Our group in the last years gained a large experience in treating lower limb PAD of CLI diabetic subjects. In our opinion it would be worthy to share our experience with physicians involved in the endovascular treatment of PAD, so we arranged this international Course to give some insight about materials and techniques used for the endovascular treatment of CLI, with particular emphasis on revascularization of extremely distal vascular territories (below-the-knee arteries, including foot arteries, and collaterals) of diabetic subjects.

The Course will last 2 days. The first day it will consist of 4 basic Courses on the following topics: 1) how to perform a safe antegrade puncture and catheterization of the common femoral artery, which is an essential step to properly treat distal vascular occlusions, hardly approachable with a controlateral technique; 2) techniques for recanalization of superficial femoral artery occlusion, which is a common finding in subjects with CLI; 3) techniques for recanalization of totally occluded infrapopliteal arteries, which is the most frequent angiographic finding in diabetic subjects with CLI and a very challenging condition for any interventionalist; 4) basic elements for surgical care of diabetic foot lesions (ulcers, deformity), which is particularly addressed to surgeons who would like to perform both endovascular treatment of CLI and surgical care of the foot. The first day of the Course will be enriched by two magistral Lectures. The first one will be about the epidemiology of peripheral vascular disease in the diabetic population, the second one will give a historical perspective on the recanalization of distal, below the knee, vascular territories.

The second day of the Course will treat essentially two aspects: 1) Presentations in the main conference room, 2) transmission of live endovascular cases from angio-rooms located in two Clinical Institutions in Brescia, Italy.

Presentations will be about several topics related to the epidemiology, pathophysiology and therapeutic strategies in diabetic subjects with PAD. Each presentation is scheduled to last 25 minutes, and 5 more minutes for discussion.

The transmission of live cases is planned to cover the majority of possible anatomical situations usually encountered by endovascular interventionists in this category of subjects: long occlusions of the superficial femoral artery, long occlusions of tibial arteries, obstructions of foot vessels. We aim to present about 15 cases.

A very interesting novelty of this Course will be the possibility for participants to use an interactive system in a dedicated room with several PC stations. The user will have the opportunity of choosing the presentation of clinical cases treated by us from a menu of several situations (stenoses and occlusions of different vascular territories). In this way, techniques and materials used will be shown to the user with an additional occasion for him to gain experience.

The Course will be essentially didactit. Phycisians interested should be: cardiologists, interventional radiologists, surgeons, vascular surgeons, diabetologists. At the end of the two working days, each participant will have taught more elements about the therotetical background of PAD and CLI in diabetic subjects, and will be able to recognize the different angiographic findings with an appropriate knowledge about the materials and techniques to treat complex arterial obstructions by an endovascular approach.

Lanfroi Graziani - Amman Bolia - Antonio Silvestro