Critical limb ischemia（CLI）presents as chronic ischemic resting pain, ulceration, and gangrene caused by an objectively confirmed arterial obstructive disease, and is regarded as a condition leading to lower limb amputation if left untreated. The prognosis of CLI is complicated by many systemic diseases, diabetes and chronic kidney disease, and is reported to be poor, with a mortality rate of 10% / year and lower limb amputation rate of 25-45% / year. Drug therapy and exercise therapy are ineffective as CLI treatments, and improvement of lower limb blood flow by blood circulation reconstruction must be considered first. Surgical bypass surgery and intravascular treatment may be employed for revascularization, but the most effective and safe revascularization procedure must be selected based on the risk / benefit balance of each treatment method in consideration of the risk factors of general anesthesia, patient background, and lesion characteristics.

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As most patients recently diagnosed with critical limb ischemia（CLI）have diabetes mellitus, it is necessary to understand the pathophysiology of ulceration and properly select treatment modalities. If the vascular lesions in CLI are mainly due to diseases of lower extremity arteries and if bypass surgery is feasible using a vein graft（diameter: 3.5 mm or more）in good vascular conditions, surgical revascularization may be a good treatment choice, as it is expected to maintain adequate blood flow and long-term patency of the bypass graft. On the other hand, for the high-risk patients with systemic arterial sclerosis, it is important to set a treatment goal properly and select endovascular therapy（EVT）or surgical revascularization carefully. The SPINACH study, a recently reported study from Japan, recommended surgical reconstruction even for patients with major tissue damage, including wound, ischemia, and foot infection（WIfI）classification W-3 or fI2-3, and/or history of minor foot amputation. As an overall treatment strategy covering numerous systemic conditions and local lesions has not been established yet, construction of a new treatment strategy is desired employing recent advances in evaluation methods, such as the WIfI classification system, and by disseminating common knowledge among different departments and professions.

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AIM: Although several endovascular therapy（EVT）procedures for critical limb ischemia（CLI）patients are required until complete wound healing, the time required for wound healing lengthens according to wound severity. We hypothesized that planned EVT may reduce the time needed for wound healing. Methods: Eighty-nine limbs for which EVT was performed at least two times were include in this study. Between January 2013 and December 2015（Conventional-EVT-group: 52-limbs）, indications for target lesion revascularization（TLR）were decided based on decreased skin perfusion pressure values or delayed wound healing. Between January 2016 and October 2016（Planned-EVT-group: 37-limbs）, TLR was carried out every two months regardless of the SPP values until complete wound healing. The time to wound healing and complete wound healing rate were compared between the two groups. Results: There was no significant difference in the number of EVT procedures between the two groups（2.0; interquartile-range, 2.0-3.0 versus 2.0; interquartile-range, 2.0-3.0; P=0.9). Although the complete wound healing rate was similar in both groups（71.2% versus 73.0%, p=1.0), the time to wound healing was significantly shorter（95 days versus 143 days, p=0.025）in the Planned-EVT-group. Conclusions: Planned-EVT is a useful strategy to shorten the time to wound healing in CLI patients with tissue loss.

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As the initial success rate of endovascular treatment of femoro-popliteal lesion has reached nearly 100%, including chronic total occlusion, long-term patency has become the main concern. For this purpose, vessel preparation is one of the most important factors for final success with all devices, including bare metal stents, drug eluting stents, drug eluting balloons, and VIABAHN. Debulking devices are available in Western countries, but not in Japan, where only scoring balloons are available. There are currently 4 different scoring balloons, NSE, Angiosculpt, Scoreflex, and Cutting balloons, in use. Proper usage of each type to reduce dissection and increase the inner lumen is necessary for initial success and long-term patency.

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The number of patients with peripheral artery disease is predicted to increase in the future. The prognosis of patients with critical limb ischemia is markedly poor and multidisciplinary treatment is required for limb salvage. Treatment for peripheral artery disease depends on the extent of symptoms or lesion localization, and should be determined considering patient characteristics. Compared with foreign countries, fewer devices are available in Japan and several techniques have been invented for successful procedures. In this report, I describe the current status of endovascular therapy for infrapopliteal lesions and techniques to achieve initial success.

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Bypass surgery（BSX）used to be the main revascularization therapy for peripheral arterial disease（PAD）. However, endovascular therapy（EVT）recently surpassed BSX due to advances in technology and evolution of devices. This also applies to critical limb ischemia（CLI）. Currently, cardiovascular interventionists play a major role in EVT. Although they can use technology based on percutaneous coronary intervention（PCI）, their knowledge of PAD is insufficient. Restenosis has been improved by drug-eluting stents in PCI, which is now an established treatment. However, restenosis after EVT is still unresolved, except for in aorto-iliac lesions. Therefore, the indications and strategy should be carefully considered. In particular, the performance of infrapopliteal EVT was reported to be poor and the restenosis rate within 3 months was over 70%（1）. As the primary goal of CLI treatment is improvement of pain and wound healing, it should not be treated by PCI. In this report, I present my opinions regarding the optimal EVT method for BTK lesions.

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Clinical outcomes of patients with critical limbs ischemia（CLI）are unfavorable. Arterial revascularization is necessary for limb salvage. Bypass surgery（BS）is the standard arterial revascularization method, but CLI patients rarely qualify as surgical candidates because of their poor clinical background, such as frailty, concomitant disease and advanced age. Therefore, less-invasive percutaneous endovascular therapy（EVT）has become popular. For limb salvage, EVT was demonstrated as sufficient and the objective performance goal was met（84% limb salvage rate at 1 year）. However, regarding wound healing, EVT still presents clinical challenges. According to recent clinical trials, approximately 20% of patients who underwent EVT had unhealed wounds, even though major amputation was successfully avoided. This percentage is larger than that after BS. Therefore, EVT needs to be improved to increase the rate of wound healing. Several clinical trials have reported that below-the-ankle（BTA）diseases result in poorer clinical outcomes, especially regarding wound healing. Thus, adjunctive EVT for BTA diseases may improve wound healing. We previously reported the clinical efficacy of BTA angioplasty in single center and multicenter trials. In this report, we summarized the results of EVT for BTA diseases.

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Japan is becoming an aging society, and the incidence of peripheral arterial disease（PAD）caused by arteriosclerosis and foot lesions due to diabetes, a lifestyle disease, as well as that of critical limb ischemia（CLI）and lower limb amputees are increasing. Catheter treatment for patients with lower extremity arterial diseases is performed at our hospital. Our hospital also has a catheter room specialized for pediatric treatment, where we employ different treatment methods and devices for combined treatments. In this report, we introduce our unique approach to CLI treatment by our medical center staff and clinical staff.

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We use the team medicine approach in podiatry, such as PAD, for inpatients. The team medicine staff, mainly nurses, performed PAD screening for 1095 patients using the perfusion index between September 2015 and September 2016. We employed the method proposed by John Kotter, termed the 8-step process for leading change, to form the medical team. The first step is to create urgency. The second step is to form a powerful coalition. Following this 8-step process, we have created a medical team including doctors, nurses, physical therapists and clerks. We collected data and investigated PAD screening, and our study results were reported at academic and local meetings. Our medical team is rapidly developing community medicine and achieving leading change with multidisciplinary medical care systems for podiatry. We report the process and method we used to construct our medical team for podiatry.

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