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

GVG Writing Group Joint guidelines of the Society for Vascular Surgery, European Society for Vascular Surgery, World Federation of Vascular Societies

Research output: Contribution to journalArticle

20 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)3S-125S.e40
JournalJournal of vascular surgery
Volume69
Issue number6
DOIs
StatePublished - Jun 2019

Fingerprint

Blood Vessels
Ischemia
Extremities
Guidelines
Amputation
Foot
Veins
Clinical Trials
Preventive Medicine
Regenerative Medicine
Gangrene
Mortality
Peripheral Arterial Disease
Toes
Smoking Cessation
Critical Care
Cell- and Tissue-Based Therapy
Genetic Therapy
Antihypertensive Agents
Prostaglandins

Keywords

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

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

GVG Writing Group Joint guidelines of the Society for Vascular Surgery, European Society for Vascular Surgery, & World Federation of Vascular Societies (2019). Global vascular guidelines on the management of chronic limb-threatening ischemia. Journal of vascular surgery, 69(6), 3S-125S.e40. https://doi.org/10.1016/j.jvs.2019.02.016

Global vascular guidelines on the management of chronic limb-threatening ischemia. / GVG Writing Group Joint guidelines of the Society for Vascular Surgery; European Society for Vascular Surgery; World Federation of Vascular Societies.

In: Journal of vascular surgery, Vol. 69, No. 6, 06.2019, p. 3S-125S.e40.

Research output: Contribution to journalArticle

GVG Writing Group Joint guidelines of the Society for Vascular Surgery, European Society for Vascular Surgery & World Federation of Vascular Societies 2019, 'Global vascular guidelines on the management of chronic limb-threatening ischemia', Journal of vascular surgery, vol. 69, no. 6, pp. 3S-125S.e40. https://doi.org/10.1016/j.jvs.2019.02.016
GVG Writing Group Joint guidelines of the Society for Vascular Surgery, European Society for Vascular Surgery, World Federation of Vascular Societies. Global vascular guidelines on the management of chronic limb-threatening ischemia. Journal of vascular surgery. 2019 Jun;69(6):3S-125S.e40. https://doi.org/10.1016/j.jvs.2019.02.016
GVG Writing Group Joint guidelines of the Society for Vascular Surgery ; European Society for Vascular Surgery ; World Federation of Vascular Societies. / Global vascular guidelines on the management of chronic limb-threatening ischemia. In: Journal of vascular surgery. 2019 ; Vol. 69, No. 6. pp. 3S-125S.e40.
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AU - Schermerhorn, Marc

AU - de Borst, Gert Jan

AU - van den Berg, Jos

AU - Bastos Goncalves, Frederico

AU - Kakkos, Stavros

AU - Koncar, Igor

AU - Lindholt, Jes

AU - Sillesen, Henrik

AU - Muñoz, Alberto

AU - Thiruvengadam, Vidyasagaran

AU - Björck, Martin

AU - Subramaniam, Peter

AU - Rajaruthnam, P.

AU - Bedi, Varinder

AU - Mulaudzi, Thanyani

AU - Komori, Kimihiro

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AU - Azuma, Nobuyoshi

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AB - 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.

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KW - Chronic limb-threatening ischemia

KW - Critical limb ischemia

KW - Diabetes

KW - Endovascular intervention

KW - Evidence-based medicine

KW - Foot ulcer

KW - Peripheral artery disease

KW - Practice guideline

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