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

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)

    Research output: Contribution to journalArticle

    26 Citations (Scopus)

    Abstract

    Guideline Summary: 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)S1-S109.e33
    JournalEuropean Journal of Vascular and Endovascular Surgery
    Volume58
    Issue number1
    DOIs
    StatePublished - Jul 1 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 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. European Journal of Vascular and Endovascular Surgery, 58(1), S1-S109.e33. https://doi.org/10.1016/j.ejvs.2019.05.006

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

    In: European Journal of Vascular and Endovascular Surgery, Vol. 58, No. 1, 01.07.2019, p. S1-S109.e33.

    Research output: Contribution to journalArticle

    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', European Journal of Vascular and Endovascular Surgery, vol. 58, no. 1, pp. S1-S109.e33. https://doi.org/10.1016/j.ejvs.2019.05.006
    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. European Journal of Vascular and Endovascular Surgery. 2019 Jul 1;58(1):S1-S109.e33. https://doi.org/10.1016/j.ejvs.2019.05.006
    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. In: European Journal of Vascular and Endovascular Surgery. 2019 ; Vol. 58, No. 1. pp. S1-S109.e33.
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    abstract = "Guideline Summary: 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",
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    AU - 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)

    AU - Conte, Michael S.

    AU - Bradbury, Andrew W.

    AU - Kolh, Philippe

    AU - White, John V.

    AU - Dick, Florian

    AU - Fitridge, Robert

    AU - Mills, Joseph L.

    AU - Ricco, Jean Baptiste

    AU - Suresh, Kalkunte R.

    AU - Murad, M. Hassan

    AU - Aboyans, Victor

    AU - Aksoy, Murat

    AU - Alexandrescu, Vlad Adrian

    AU - Armstrong, David

    AU - Azuma, Nobuyoshi

    AU - Belch, Jill

    AU - Bergoeing, Michel

    AU - Bjorck, Martin

    AU - Chakfé, Nabil

    AU - Cheng, Stephen

    AU - Dawson, Joseph

    AU - Debus, Eike S.

    AU - Dueck, Andrew

    AU - Duval, Susan

    AU - Eckstein, Hans H.

    AU - Ferraresi, Roberto

    AU - Gambhir, Raghvinder

    AU - Garguilo, Mauro

    AU - Geraghty, Patrick

    AU - Goode, Steve

    AU - Gray, Bruce

    AU - Guo, Wei

    AU - Gupta, Prem C.

    AU - Hinchliffe, Robert

    AU - Jetty, Prasad

    AU - Komori, Kimihiro

    AU - Lavery, Lawrence

    AU - Liang, Wei

    AU - Lookstein, Robert

    AU - Menard, Matthew

    AU - Misra, Sanjay

    AU - Miyata, Tetsuro

    AU - Moneta, Gregory (Greg)

    AU - Munoa Prado, Jose A.

    AU - Munoz, Alberto

    AU - Paolini, Juan E.

    AU - Patel, Manesh

    AU - Pomposelli, Frank

    AU - Powell, Richard

    AU - Robless, Peter

    PY - 2019/7/1

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    N2 - Guideline Summary: 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.

    AB - Guideline Summary: 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.

    KW - Bypass surgery

    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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