Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, GVG Writing Group., et al.
Journal of vascular surgery. Date of publication 2019 Jun 1;volume 69(6S):3S-125S.e40.
1. J Vasc Surg. 2019 Jun;69(6S):3S-125S.e40. doi: 10.1016/j.jvs.2019.02.016. Epub
2019 May 28.
Global vascular guidelines on the management of chronic limb-threatening
ischemia.
Conte MS(1), Bradbury AW(2), Kolh P(3), White JV(4), Dick F(5), Fitridge R(6),
Mills JL(7), Ricco JB(8), Suresh KR(9), Murad MH(10); GVG Writing Group.
Collaborators: Aboyans V, Aksoy M, Alexandrescu VA, 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, Prado JAM, Munoz A, Paolini JE, Patel M,
Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S,
Vega De Ceniga M, Veller M, Vermassen F, Wang J, Wang S.
Author information:
(1)Division of Vascular and Endovascular Surgery, University of California, San
Francisco, Calif. 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, Ill.
(5)Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen,
Switzerland.
(6)Department of Vascular and Endovascular Surgery, The University of Adelaide
Medical School, Adelaide, South Australia.
(7)Division of Vascular Surgery and Endovascular Therapy, Baylor College of
Medicine, Houston, Tex.
(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, Minn.
Erratum in
J Vasc Surg. 2019 Aug;70(2):662.
Comment in
J Vasc Surg. 2019 Jun;69(6S):1S-2S.
J Vasc Surg. 2019 Jun;69(6):1653-1654.
J Vasc Surg. 2020 Jan;71(1):348-349.
J Vasc Surg. 2020 Jan;71(1):348.
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.
Copyright © 2019 Society for Vascular Surgery and European Society for Vascular
Surgery. Published by Elsevier Inc. All rights reserved.
DOI: 10.1016/j.jvs.2019.02.016
PMID: 31159978 [Indexed for MEDLINE]
