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

Publication ,  Journal Article
Conte, MS; Bradbury, AW; Kolh, P; White, JV; Dick, F; Fitridge, R; Mills, JL; Ricco, J-B; Suresh, KR; Murad, MH; Aboyans, V; Aksoy, M; Guo, W ...
Published in: Eur J Vasc Endovasc Surg
July 2019

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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Published In

Eur J Vasc Endovasc Surg

DOI

EISSN

1532-2165

Publication Date

July 2019

Volume

58

Issue

1S

Start / End Page

S1 / S109.e33

Location

England

Related Subject Headings

  • Treatment Outcome
  • Specialties, Surgical
  • Societies, Medical
  • Severity of Illness Index
  • Quality of Life
  • Prevalence
  • Practice Guidelines as Topic
  • Peripheral Arterial Disease
  • Lower Extremity
  • Limb Salvage
 

Citation

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Conte, M. S., Bradbury, A. W., Kolh, P., White, J. V., Dick, F., Fitridge, R., … GVG Writing Group for the Joint Guidelines of the Society for Vascular Surgery (SVS), European Society for Vascular Surgery (ESVS), and World Federation of Vascular Societies (WFVS), . (2019). Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg, 58(1S), S1-S109.e33. https://doi.org/10.1016/j.ejvs.2019.05.006
Conte, Michael S., Andrew W. Bradbury, Philippe Kolh, John V. White, Florian Dick, Robert Fitridge, Joseph L. Mills, et al. “Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.Eur J Vasc Endovasc Surg 58, no. 1S (July 2019): S1-S109.e33. https://doi.org/10.1016/j.ejvs.2019.05.006.
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.
Conte, Michael S., et al. “Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.Eur J Vasc Endovasc Surg, vol. 58, no. 1S, July 2019, pp. S1-S109.e33. Pubmed, doi:10.1016/j.ejvs.2019.05.006.
Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco J-B, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu V-A, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S, GVG Writing Group for the Joint Guidelines of the Society for Vascular Surgery (SVS), European Society for Vascular Surgery (ESVS), and World Federation of Vascular Societies (WFVS). Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg. 2019 Jul;58(1S):S1-S109.e33.
Journal cover image

Published In

Eur J Vasc Endovasc Surg

DOI

EISSN

1532-2165

Publication Date

July 2019

Volume

58

Issue

1S

Start / End Page

S1 / S109.e33

Location

England

Related Subject Headings

  • Treatment Outcome
  • Specialties, Surgical
  • Societies, Medical
  • Severity of Illness Index
  • Quality of Life
  • Prevalence
  • Practice Guidelines as Topic
  • Peripheral Arterial Disease
  • Lower Extremity
  • Limb Salvage