After three years of work, research and study, vascular experts from around the world have released a new, far-reaching global guideline on the management of chronic limb-threatening ischemia (CLTI), formerly known as critical limb ischemia. SVS members are urged to review the guideline and submit comments.
The nearly guideline includes just more than 100 specific recommendations. It was developed by members of the Society for Vascular Surgery, the European Society for Vascular Surgery and the World Federation of Vascular Societies, with a co-editor from each association and 57 additional authors.
Its primary goal is to improve the quality of care for patients with CLTI and those at risk for it. Identifying key research priorities is an important secondary goal.
Major recommendations cover the need for comprehensive assessments in patients with suspected CLTI, optimal medical therapy including a variety of treatments for patients with CLTI and prompt and effective revascularization for patients with advanced ischemia and limb threat. “The optimal initial revascularization strategy in CLTI depends on patient risk and life expectancy, severity of limb threat and anatomic complexity,” the guideline states.
A major change is the name itself. The term “critical limb ischemia (CLI)” is “outdated and fails to encompass the full spectrum” of patients evaluated and treated for limb-threatening ischemia, the authors said. CLTI “acknowledges the broad range of ischemia, neuropathy, and limb threat that are evaluated and managed by vascular specialists around the globe,” said Michael Conte, MD, SVS co-editor. Other co-editors are Andrew Bradbury, MD, World Federation and Philippe Kolh, MD, ESVS.
Dr. Conte outlined other major changes.
- Staging Anatomy: GLASS Added
Besides endorsing the SVS Threatened Limb Classification System based on grading wound, ischemia and foot infection (WIfI) in the affected limb, the guideline introduces the Global Limb Anatomic Staging System (GLASS). GLASS incorporates the integrated complexity of disease along a selected target artery path (TAP) from groin to foot. GLASS relates disease pattern to anticipated immediate technical success and 12-month limb-based patency (LBP) following intervention.
- Decision-Making: Have a PLAN:
“Perhaps most notably, the guideline supports a structured approach to decision-making regarding revascularization based on Patient risk, Limb severity and ANatomic complexity (PLAN), in that order of priority,” said Dr. Conte. “The guideline seeks to provide a new foundation for practice but also for data collection to support Evidenced-Based Revascularization in CLTI.”
The document includes key research priorities in each section, where efforts and resources should be focused to improve patient care and advance the science in this arena.
The collaboration between expert vascular specialists from around the world has created a unique practice guideline, reflecting the spectrum of the disease and approaches seen worldwide, said Dr. Conte. Participants, meanwhile, spanned six continents and all specialties treating CLTI: vascular surgery, interventional cardiology, interventional radiology, vascular medicine and podiatry.
The guideline will be available for review and comment soon.