Clinical guidelines on chronic limb-threatening ischemia were released in June 2019 by the Society for Vascular Surgery, European Society for Vascular Surgery, and World Federation of Vascular Societies.[1]
Definitions and Nomenclature
Evaluate for ischemia and determine its severity using objective hemodynamic tests in all patients with suspected chronic limb-threatening ischemia (CLTI).
Grade wound extent, degree of ischemia, and infection severity with a lower-extremity threatened-limb classification staging system to guide clinical treatment in all patients with suspected CLTI.
Diagnosis and Limb Staging
A detailed history should be performed in all patients with suspected CLTI to determine symptoms, cardiovascular risk factors, and medical history.
A complete cardiovascular physical examination should be performed in all patients with suspected CLTI.
A complete foot examination should be performed in all patients with pedal tissue loss and suspected CLTI, including a neuropathy assessment and a probe-to-bone test of any open ulcers.
Toe pressure (TP) and toe-brachial index (TBI) should be measured in all patients with tissue loss and suspected CLTI.
High-quality angiographic imaging of the lower limb (including the ankle and foot) should be performed in all patients with suspected CLTI who may be candidates for revascularization.
Analgesics should be prescribed to patients with CLTI who have ischemic rest pain of the lower extremity and foot until pain resolves following revascularization.
Chronic severe pain should be treated with acetaminophen in combination with opioids in patients with CLTI.
An integrated limb-based anatomic staging system (eg, Global Limb Anatomic Staging System [GLASS]) should be used to define the complexity of a preferred target artery path (TAP) and to aid in revascularization (EBR) in patients with CLTI.
Strategies for Evidence-Based Revascularization
A vascular specialist should be consulted in all cases of suspected CLTI to consider limb salvage except when major amputation is considered medically urgent.
Patients with a limited life expectancy, unsalvageable limb, or poor functional status should be offered primary amputation or palliation after shared decision-making.
The periprocedural risk should be assessed and life expectancy estimated in patients with CLTI who are candidates for revascularization.
Urgent surgical drainage and debridement (including minor amputation, if needed) should be performed and antibiotic therapy initiated in all patients with suspected CLTI who have wet gangrene or deep-space foot infection.
Limb staging should be repeated following surgical drainage, debridement, minor amputation, or correction of inflow disease (aortoiliac [AI], common and deep femoral artery disease) and before subsequent major treatment decisions.
Revascularization should not be performed in patients without significant ischemia (Wound, Ischemia, and foot Infection [WIfI] ischemia grade 0) unless an isolated region of poor perfusion in conjunction with major tissue loss (eg, WIfI wound grade 2 or 3) can be effectively targeted and the wound progresses or fails to decrease in size by 50% or more within 4 weeks despite appropriate infection control, wound care, and offloading.
Revascularization should be offered to all average-risk patients with advanced limb-threatening conditions (eg, WIfI stage 4) and significant perfusion deficits (eg, WIfI ischemia grades 2 and 3).
The anatomic pattern of disease and preferred TAP should be defined with an integrated lib-based staging system in all patients with CLTI who are candidates for revascularization.
When available, ultrasonographic vein mapping should be performed in all patients with CLTI who are candidates for surgical bypass.
The ipsilateral great saphenous vein (GSV) and small saphenous vein should be mapped to plan the surgical bypass.
Veins in the contralateral leg and both arms should be mapped if the ipsilateral vein is insufficient.
A patient with CLTI should not be considered as unsuitable for revascularization until imaging studies are reviewed and the patient is clinically evaluated by a qualified vascular specialist.
Inflow disease should be corrected first in patients with CLTI who have both inflow and outflow disease.
The decision for staged versus combined inflow and outflow revascularization should be based on risk and limb threat.
Inflow disease alone should be corrected in patients with CLTI who have multilevel disease and low-grade ischemia (eg, WIfI ischemia grade 1) or limited tissue loss (eg, WIfI wound grade 0 or 1) and whenever the risk-benefit of additional outflow reconstruction is high or initially unclear.
The limb should be restaged and hemodynamic assessment repeated following inflow correction in patients with CLTI who have both inflow and outflow disease.
Open common femoral artery (CFA) endarterectomy with patch angioplasty should be performed, with or without extension into the profunda femoris artery (PFA), in patients with CLTI who have hemodynamically significant disease of the common and deep femoral arteries (>50% stenosis).
Endovascular treatment should be considered for significant CFA disease in patients who are deemed to be at high surgical risk or to have a hostile groin.
The preferred conduit for infrainguinal bypass surgery is autologous vein in patients with CLTI
Intraoperative imaging (angiography, duplex ultrasonography, or both) should be performed upon completion of open bypass surgery for CLTI and significant technical defects corrected, if feasible, during the index operation.
Nonrevascularization Treatments
Vasoactive drugs and defibrinating agents (ancrod) should not be offered to patients in whom revascularization is not possible
Hyperbaric oxygen therapy (HBOT) should not be offered to improve limb salvage in patients with CLTI who have severe uncorrected ischemia (eg, WIfI ischemia grade 2 or 3).
Optimal wound care should be continued until the lower extremity wound has completely healed or amputation is performed.
Biologic and Regenerative Medicine Approaches
Therapeutic angiogenesis should be restricted for patients with CLTI who are enrolled in a registered clinical trial.
After shared decision-making, primary amputation should be offered to patients with CLTI who have an unsalvageable or pre-existing dysfunctional limb, a short life expectancy, or poor functional status.
A multidisciplinary rehabilitation team should be involved from the time of decision to amputate through successful completion of rehabilitation.
Patients with CLTI who have undergone amputation should be monitored at least yearly to track disease progression in the contralateral limb, to maintain optimal medical therapy, and to manage risk factors.
Following lower-extremity revascularization, optimal medical therapy for peripheral artery disease (PAD), including long-term antiplatelet and statin therapies, should be continued.
Patients who have undergone lower-extremity vein bypass for CLTI should be observed regularly for at least 2 years. The clinical surveillance program should include interval history, pulse examination, and assessment of resting APs and TPs. Duplex ultrasonography should also be considered.
Patients who have undergone lower-extremity prosthetic bypass for CLTI should be observed regularly for at least 2 years, with interval history, pulse examination, and measurement of resting APs and TPs.
Patients who have undergone infrainguinal endovascular interventions for CLTI should be observed in a surveillance program that includes clinical visits, pulse examination, and noninvasive testing (resting APs and TPs).
Intervention should be offered if vein graft lesions are detected on duplex ultrasonography in patients with an associated peak systolic velocity (PSV) of >300 cm/s and a PSV ratio >3.5 or grafts with low velocity (midgraft PSV <45 cm/s) to maintain patency.
Long-term surveillance, including duplex ultrasonographic graft scanning, should be maintained following surgical or catheter-based revision of a vein graft to evaluate for recurrent graft-threatening lesions.
Mechanical offloading should be provided as a primary component of care in all patients with CLTI who have pedal wounds.
For more information, please go to Peripheral Arterial Occlusive Disease.
For more Clinical Practice Guidelines, please go to Guidelines.
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg. 2019 Jul. 58 (1S):S1-S109.e33. https://www.jvascsurg.org/article/S0741-5214(19)30321-0/pdf
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From www.medscape.com
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Medical Management
Cardiovascular risk factors should be evaluated in all patients with suspected CLTI.
Modifiable risk factors should be managed in all patients with suspected CLTI.
Antiplatelet therapy should be administered to all patients with CLTI.
Systemic vitamin K antagonists should be avoided in the treatment of lower extremity atherosclerosis in patients with CLTI.
Statin therapy (moderate- or high-intensity) should be administered to patients with CLTI to reduce the likelihood of all-cause and cardiovascular mortality.
Hypertension should be modified to target levels of <140 mm Hg systolic and <90 mm Hg diastolic in patients with CLTI.
Metformin is the primary hypoglycemic agent in patients with type 2 diabetes mellitus (DM) and CLTI.
Smoking-cessation interventions should be offered to all patients with CLTI who use tobacco products.
Smokers or former smokers with CLTI should be inquired about the status of tobacco use at every visit.
