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Eur J Vasc Endovasc Surg. 2019 Jul;58(1S):S1-S109.e33. doi: 10.1016/j.ejvs.2019.05.006. Epub 2019 Jun 8.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.

Author information

1
Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA. Electronic address: michael.conte2@ucsf.edu.
2
Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom.
3
Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium.
4
Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA.
5
Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland.
6
Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia.
7
Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.
8
Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France.
9
Jain Institute of Vascular Sciences, Bangalore, India.
10
Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA.
11
Department of Cardiology, Dupuytren, University Hospital, France.
12
Department of Vascular Surgery American, Hospital, Turkey.
13
University of Liège CHU Sart-Tilman Hospital, Belgium.
14
University of Southern California, USA.
15
Asahikawa Medical University, Japan.
16
Ninewells Hospital University of Dundee, UK.
17
Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile.
18
Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden.
19
University Hospital of Strasbourg, France.
20
The University of Hong Kong, Hong Kong.
21
Royal Adelaide Hospital & University of Adelaide, Australia.
22
University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany.
23
Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada.
24
Cardiovascular Division, University of, Minnesota Medical School, USA.
25
Technical University of Munich, Germany.
26
Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy.
27
King's College Hospital, London, UK.
28
Diagnostica e Sperimentale, University of Bologna, Italy.
29
Washington University School of Medicine, USA.
30
Sheffield Vascular Institute, UK.
31
Greenville Health System, USA.
32
301 General Hospital of PLA, Beijing, China.
33
Care Hospital, Banjara Hills, Hyderabad, India.
34
University of Bristol, UK.
35
Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.
36
Nagoya University Graduates School of Medicine, Japan.
37
UT Southwestern Medical Center, USA.
38
Renji Hospital, School of Medicine, Shanghai Jiaotong University, China.
39
Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai.
40
Brigham and Women's Hospital, USA.
41
Mayo Clinic, USA.
42
Sanno Hospital and Sanno Medical Center, Japan.
43
Oregon Health & Science University, USA.
44
Clinic Venart, Mexico.
45
Colombia National University, Colombia.
46
Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina.
47
Division of Cardiology, Duke University Health System, USA.
48
St. Elizabeth's Medical Center, USA.
49
Dartmouth-Hitchcock, USA.
50
Mt. Elizabeth Hospital, Singapore.
51
Amputation Prevention Centers of America, USA.
52
University of Massachusetts, USA.
53
Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA.
54
Greenville Health Center/USC School of Medicine Greenville, USA.
55
Hospital de Galdakao-Usansolo, Bizkaia, Spain.
56
University of the Witwatersrand, Johannesburg, South Africa.
57
Ghent University Hospital, Belgium.
58
The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.

Abstract

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.

KEYWORDS:

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

PMID:
31182334
DOI:
10.1016/j.ejvs.2019.05.006

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