Application of the “ORC” to Critical Limb Ischemia

To the Editors:

We would like to recognize the significant contribution of Katib et al ¹ regarding an endovascular approach to the treatment of critical limb ischemia (CLI). As father and son physicians, a cardiothoracic and vascular surgeon (RAD) and an interventional cardiologist (RSD), respectively, we have both been engaged in the battle against limb loss due to CLI. We found the commentary by Stegman and Shishehbor ² excellent, particularly the figure demonstrating a logical algorithm to approach these patients. It was reminiscent of the “ORC” approach to patients with thoracic cancers that was proposed years ago (by RAD). ³ In that scheme, the “O” corresponded to the operability of the patient, the “R” stood for resectability, and the “C” for curability. In our modified algorithm, the following is a simple and rational approach to patients with CLI.

OPEN IN VIEWER

O for operable	Is the patient an acceptable candidate for either endovascular or open surgical repair?
R for revascularizable	Is there a distal target for bypass? Is endovascular lesion crossing possible?
C for curable	Will healing occur after revascularization or are there significant comorbidities (eg, infection, edema, immobility, etc) that preclude healing?

With a thoughtful, systematic approach to critical limb ischemia, we will be able to salvage many limbs and increase the quality of life for our patients.