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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Chronic limb-threatening ischaemia

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

CLTI needs urgent vascular referral. Wet gangrene, spreading infection/sepsis, rapidly worsening pain or a diabetic foot with ulcer plus limb ischaemia is a limb- and sometimes life-threatening emergency requiring same-day acute assessment.

Synopsis

Recognise ischaemic rest pain and tissue loss, protect the foot and secure urgent multidisciplinary revascularisation assessment before preventable amputation.

  • CLTI is chronic PAD with ischaemic rest pain, non-healing ulceration or gangrene; it replaces the older term critical limb ischaemia.
  • Forefoot pain that is worse when supine and relieved by hanging the foot down is classic ischaemic rest pain.
  • Tissue loss is often distal and punched out, with a cool hairless foot, delayed refill and reduced pulses; neuropathy may blunt pain.
  • Refer urgently to a vascular multidisciplinary team—analgesia and dressings alone are not definitive care.
  • Measure ABPI, but do not exclude PAD from a normal or high value in diabetes or CKD because calcified arteries may be incompressible.
  • Toe pressure/toe-brachial index and Doppler waveforms help when ABPI is unreliable; anatomical imaging follows when revascularisation is being considered.
  • Offer angioplasty or bypass when revascularisation is required; major amputation should not occur until revascularisation options have been considered by a vascular team.
  • Treat smoking, lipids, antiplatelet indication, diabetes, blood pressure, infection and foot pressure as part of limb salvage, not as substitutes for restoring flow.

Key red flags

Ischaemic rest pain

Persistent forefoot/toe pain, often nocturnal and worse with elevation, relieved transiently by dependency; requires urgent vascular assessment.

Infected or wet gangrene

Spreading erythema, purulence, malodour, crepitus, systemic illness or wet tissue necrosis requires same-day surgical/vascular and antimicrobial care.

Acute-on-chronic deterioration

A sudden increase in pain, coldness, sensory loss or weakness suggests superimposed ALI and moves the patient to an emergency pathway.

Investigation priorities

01
ABPI with Doppler waveformsFirst step

Objectify PAD and describe arterial signals.

Management branches

urgentNew CLTI

Rest pain, non-healing arterial ulcer or gangrene without acute motor/sensory loss.

  1. First: urgent vascular MDT referral; document wound, pulses/Doppler, sensation, infection and analgesic needs.
  2. Next: protect the foot, avoid trauma and inappropriate compression, and obtain ABPI plus toe/waveform testing where needed.
  3. Next: perform anatomical imaging when revascularisation is being planned and optimise antiplatelet, lipid, smoking, BP and diabetes care.
  4. Escalation: same-day acute referral for wet gangrene, spreading infection, sepsis or acute-on-chronic neurological change.

Key medicines

Clopidogrel75 mg orally once daily.Check bleeding, interacting anticoagulants/antiplatelets and planned surgery; do not add to full anticoagulation automatically.
Atorvastatin80 mg orally once daily for secondary prevention; use a lower dose if interactions, adverse-effect risk or patient preference require it.Check baseline liver tests; review interactions and muscle symptoms. Avoid during pregnancy and breastfeeding under the product information.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG147: Peripheral arterial disease—recommendationsUrgent management, imaging, revascularisation and amputation principles.
  • NICE CKS: Chronic limb-threatening ischaemiaUK primary-care recognition, urgent referral and analgesia.
  • 2024 ESC Guidelines for peripheral arterial and aortic diseasesContemporary CLTI staging and revascularisation context.
  • NICE NG19: Diabetic foot problemsImmediate referral and infection/foot-care pathways.
  • NICE NG238: CVD risk reduction and lipid modificationSecondary-prevention statin treatment and monitoring.
  • eMC: Sevredol immediate-release morphine SmPCAdult immediate-release dose and individual titration context.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom