Chronic Limb-Threatening Ischemia
Key Points
Key Points
- Chronic limb-threatening ischemia (CLTI) represents the end stage of peripheral artery disease (PAD), a problem of growing prevalence and increased health care costs around the globe. CLTI is a highly morbid disease, incurring significant mortality, limb loss, pain, and diminished health-related quality of life.
- Vascular specialists evaluate patients with CLTI across a broad range of disease severity. This guideline promotes the use of the SVS Threatened Limb Classification System (WIfI) for clinical staging and proposes the Global Anatomic Staging System (GLASS) for defining the extent and complexity of PAD along the Target Artery Pathway (TAP).
- Objective measurement of perfusion (eg, ankle, toe pressures) is essential for accurate staging of CLTI. The presence and degree of ischemia is an important determinant of risk of limb loss and treatment approach.
- Optimum medical therapy reduces overall mortality as well as major adverse cardiovascular and limb-related events. All vascular specialists treating CLTI should assess and provide evidence-based recommendations on lifestyle and medical therapies.
- The goals of limb treatment in CLTI are to prevent amputation, maintain function, reduce pain, and heal wounds. Selection of appropriate candidates for revascularization depends on careful assessment of patient risk, functional status, clinical severity and salvageability of the affected foot.
- Structured decision-making in CLTI follows the PLAN concept, assessing (in order) Patient risk, Limb stage, and Anatomic complexity of disease to define appropriate candidates for, and the best approach to revascularization in individual patients.
- The effectiveness of non-revascularization treatments for CLTI including pharmacotherapies, hyperbaric oxygen, pneumatic compression, spinal cord stimulation, cell and gene therapies appears limited and further research is needed to establish their role, if any.
- Patients with CLTI require long-term surveillance for disease recurrence/progression and should be maintained on appropriate risk factor modification and cardiovascular protective medications.
- Future clinical trials in CLTI should exclude patients with intermittent claudication, incorporate stratification by disease stage, employ meaningful clinical and patient-oriented outcomes, and have appropriate follow up duration to better define clinical and cost effectiveness.
Diagnosis
...iagnosis
Figure 1. Flow diagram for the investigation of pa...
...ested algorithm for anatomic imaging in pa...
...igure 3. PLAN framework of clinical de...
Diagnosis – Limb Staging
...s – Limb Staging...
...e 1. Wound grading in Wound, Ischem...
...2. Ischemia grading in Wound, Ischemia, and foot...
...nfection grading in Wound, Ischemia, and fo...
...IfI Clinical Limb Stage (Based on est...
...benefit of performing revascularization in CLT...
Diagnosis – Global Anatomic Staging System (GLASS)
...agnosis – Global Anatomic Staging System (...
...6. Femoropopliteal (FP) disease grading...
...gure 7. Infrapopliteal (IP) disease gra...
...ssignment of GLASS stageHaving trouble viewing tab...
...8. Flow chart illustrating application o...
...igure 9. Inframalleolar (IM)/pedal diseas...
...tive summary of GLASS stages of infrainguinal...
...10. Preferred initial revascularizati...
Recommendations
...mmendation...
Definitions and nomenc...
...ve hemodynamic tests to determine the pre...
...ower extremity threatened limb classif...
...emiology and risk factors for CLTI...
...ommendations (, )681...
...sis and limb staging in CL...
...a detailed history to determine symptoms, past med...
...te cardiovascular physical examination of all...
...plete examination of the foot, inc...
...and ABI as the first-line noninvasive test in...
...e TP and TBI in all patients with...
...sider using alternative methods for...
...r DUS imaging as the first arterial imaging mo...
...nsider noninvasive vascular imaging modalities...
...tain high-quality angiographic imaging of...
...ical management...
...te cardiovascular risk factors in all patient...
Manage all modifiable risk factors...
...nts with CLTI with an antiplatelet agent. ( S ,...
...lopidogrel as the single antiplatelet a...
...-dose aspirin and rivaroxaban, 2.5 mg twice da...
...use systemic vitamin K antagonists...
...- or high-intensity statin therapy to reduce all...
Control hypertension to target levels of...
...of type 2 DM in CLTI patients to ach...
...metformin as the primary hypoglyc...
...er withholding metformin immediately b...
...fer smoking cessation interventions (pharma...
...sk all CLTI patients who are smokers or form...
...analgesics of appropriate strength for CLTI patie...
In CLTI patients with chronic sever...
...GLASS for CLTI...
...an integrated, limb-based anatomic staging system...
...egies for EBR...
...ll patients with suspected CLTI to...
...imary amputation or palliation to patients wit...
...procedural risk and life expectancy in pa...
...e a CLTI patient as average surgical risk...
...LTI patient as high surgical risk whe...
...ed threatened limb classification system...
...form urgent surgical drainage and débrideme...
...imb staging after surgical drainage, débridement,...
...revascularization in the absence of signif...
...rform revascularization in very-low–...
...arization to all average-risk patien...
Consider revascularization for aver...
...scularization in average-risk patients w...
...revascularization in average-risk pat...
...h-quality angiographic imaging with dedi...
...e an integrated limb-based staging system (e...
...rasound vein mapping when available in all CLTI...
...ilateral GSV and small saphenous vein f...
...lassify a CLTI patient as being unsuitable...
...flow disease first when both inflow...
...n for staged vs. combined inflow and outflow r...
...disease alone in CLTI patients with mu...
...imb and repeat the hemodynamic assessment...
...imultaneous inflow and outflow revascu...
...e an endovascular-first approach for treatme...
...onsider surgical reconstruction for the trea...
...CFA endarterectomy with patch angiopl...
...er a hybrid procedure combining open CFA endartere...
...dovascular treatment of significant C...
...nts in the CFA and do NOT place stents...
...ect hemodynamically significant (≥50% stenosis)...
...-risk CLTI patients with infrainguinal disease,...
...ar revascularization when technically feasible f...
...er endovascular revascularization for h...
...ovascular revascularization for high-ri...
...dovascular revascularization for high-...
...en surgery in selected high-risk patients...
...ider angiosome-guided revascularization in patie...
...ing FP disease in CLTI patients by endovasc...
...ologous vein as the preferred conduit for infraing...
...id using a nonautologous conduit for in...
...aoperative imaging (angiography, DUS, or bot...
...ascularization treatments of the lim...
...reduce the risk of amputation and to...
...r limb salvage in CLTI patients in whom rev...
...onsider IPC therapy in carefully s...
Do NOT offer prostanoids for limb salvage...
...o NOT offer vasoactive drugs or defibr...
...offer HBOT to improve limb salvage...
...ue to provide optimal wound care until the lower e...
...egenerative medicine approaches in CLTI...
...ct use of therapeutic angiogenesis to CLT...
...role of minor and major amputations...
...sider transmetatarsal amputation of the forefoot i...
...mary amputation to CLTI patients who...
...ary amputation for patients with CLTI who have a...
...revascularization to improve the possibility of...
...ider a TKA or AKA in patients who are no...
...lve a multidisciplinary rehabilitation team from...
...to observe CLTI patients who have undergon...
...ostprocedural care and surveillance after infrain...
Continue best medical therapy for PAD, includin...
...ng cessation in all CLTI patients who have u...
...DAPT (aspirin plus clopidogrel) in patients who h...
...PT (aspirin plus clopidogrel) in pat...
...r 1–6 months in patients undergoing repe...
...ents who have undergone lower extremit...
...ents who have undergone lower extremity prosthetic...
...patients who have undergone infrainguinal endovasc...
Consider performing additional imaging in...
...ntervention for DUS-detected vein gra...
...long-term surveillance after surgic...
...er arterial imaging after endovascular inte...
...ervention for patients with DUS-detected restenosi...
...chanical offloading as a primary component fo...
...ide counseling on continued protection of...
...tudy designs and trial end points...
...arch framework such as the IDEAL for gathering...
...ncourage funders, journal reviewers...
...Ts are not feasible, use the OPG b...
...ufficient enrollment, limit RCT exclusion criteri...
...esign RCTs, prospective cohort studie...
...grated, limb-based threatened limb c...
...scribe outcomes in CLTI trials using a combi...
...gulatory trials aimed at obtaining pre...
...up patients in trials for a time s...
...me-integrated measure of clinical disease se...
...h all CLTI trial protocols together with t...
...uct postmarketing surveillance data col...
...ical trial data to allow subsequent...
...ess the quality of evidence in CLTI research usin...