A 58-year-old woman with diabetes and hypertension presents with rest pain in her left foot and a non-healing ulcer over the lateral malleolus. Angiography reveals critical stenosis of the anterior tibial and peroneal arteries. Regarding revascularization strategies and medical management in critical limb ischaemia (CLI), all of the following are correct EXCEPT:

Explanation

## Revascularization and Medical Management in Critical Limb Ischaemia ### Endovascular vs. Open Surgery **High-Yield:** Current evidence and guidelines favour **endovascular intervention as first-line** revascularization in CLI patients with suitable anatomy. The BASIL trial and subsequent meta-analyses support endovascular-first strategy for infrainguinal disease, with open surgery reserved for failed endovascular attempts or unsuitable anatomy. This statement is TRUE. **Clinical Pearl:** Even if endovascular fails, patients retain the option of open surgery; the reverse (open first, then endovascular) limits future options. ### Antiplatelet Therapy in Infrainguinal Bypass **Key Point:** Dual antiplatelet therapy (aspirin + clopidogrel) is SUPERIOR to aspirin monotherapy in preventing infrainguinal bypass graft thrombosis. The CASPAR trial demonstrated that dual therapy reduces graft occlusion at 1 year compared to aspirin alone. The statement claims aspirin monotherapy is superior — this is FALSE and is the correct answer to an EXCEPT question. **Mnemonic:** **"CASPAR: Clopidogrel + Aspirin Superior for Patency After Revascularization"** | Antiplatelet Strategy | Graft Patency at 1 Year | Evidence | | --- | --- | --- | | Aspirin monotherapy | ~75% | Standard, but inferior | | Aspirin + Clopidogrel | ~82% | CASPAR trial; preferred | ### Prostanoids in CLI **Key Point:** Prostanoids (iloprost, misoprostol) improve ulcer healing and reduce amputation risk in CLI patients when revascularization is not feasible or has failed. They act via vasodilation and platelet inhibition. Multiple RCTs support their use in non-revascularizable CLI. This statement is TRUE. ### Revascularization vs. Amputation **Clinical Pearl:** Current guidelines recommend attempting revascularization in all CLI patients with reasonable life expectancy (>2 years) and anatomically feasible disease, even if the anatomy is complex. Amputation is reserved for non-revascularizable disease, severe infection, or patient refusal. This statement is TRUE.