Global vascular guidelines on the management of chronic limb-threatening ischemia

Bypass surgery; Chronic limb-threatening ischemia; Critical limb ischemia; Diabetes; Endovascular intervention; Evidence-based medicine; Foot ulcer; Peripheral artery disease; Practice guideline; Article

Abstract :

[en] Chronic limb-threatening ischemia (CLTI)is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG)are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD)in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI)is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR)hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP)and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen)has not been established. Regenerative medicine approaches (eg, cell, gene therapies)for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative. © 2019 Society for Vascular Surgery and European Society for Vascular Surgery

Disciplines :

Surgery

Author, co-author :

Conte, M. S.; Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif, United States

Bradbury, A. W.; Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom

Kolh, Philippe ; Université de Liège - ULiège > Département des sciences biomédicales et précliniques > Biochimie et physiologie générales, humaines et path.

White, J. V.; Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill, United States

Dick, F.; Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland

Fitridge, R.; Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, Australia

Mills, J. L.; Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex, United States

Ricco, J.-B.; Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France

Suresh, K. R.; Jain Institute of Vascular Sciences, Bangalore, India

Murad, M. H.; Mayo Clinic Evidence-Based Practice Center, Rochester, Minn, United States

More authors (43 more)

Title :

Global vascular guidelines on the management of chronic limb-threatening ischemia

Publication date :

2019

Journal title :

Journal of Vascular Surgery

ISSN :

0741-5214

eISSN :

1097-6809

Publisher :

Mosby Inc.

Volume :

Issue :

Pages :

3S-125S.e40

Peer reviewed :

Peer Reviewed verified by ORBi

Available on ORBi :

since 24 September 2019

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