After four years of work and research, vascular experts from around the world have released a new, far-reaching global guideline on managing chronic limb-threatening ischemia (CLTI), a problem of increasing prevalence and higher health care costs world-wide.
The Journal of Vascular Surgery is publishing the guideline, with 113 specific recommendations, as a supplement to the June edition. It is to available online before late May.
The guideline creates a new conceptual framework for treating CLTI, the end-stage of peripheral arterial disease. The document encompasses nomenclature, disease staging and a platform for evidence-based revascularization that will allow for future evolution and quality improvement in the field.
Three co-editors, one each from the Society for Vascular Surgery (Michael Conte, M.D.), the European Society for Vascular Surgery (Philippe Kolh, M.D.) and the World Federation of Vascular Societies (Andrew Bradbury, M.D.), and nearly 60 additional authors worked on the guideline. Participants spanned six continents and represented all specialties treating CLTI.
In addition, an extensive evidence review was undertaken, directed by a methodologist, to support the writing group’s work. The final result is a unique practice guideline, reflecting the spectrum of the disease and approaches seen worldwide, said Dr. Conte.
Major recommendations cover the need for comprehensive assessments in patients with suspected CLTI; optimal medical therapy, including a variety of treatments for CLTI patients; and prompt and effective revascularization for patients with advanced ischemia and limb threat. The document also outlines the importance of an individualized approach to improve patient care and reduce limb loss.
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 The term “critical limb ischemia (CLI)” is “outdated and fails to encompass the full spectrum” of patients evaluated and treated for limb-threatening ischemia, the authors said.
Other significant changes include:
- Staging Limb Threat and Anatomic Complexity: WIfI and GLASS
The guideline endorses the SVS Threatened Limb Classification System based on grading wound, ischemia and foot infection (WIfI) in the affected limb. And it introduces the Global Limb Anatomic Staging System (GLASS) to stratify the patterns of arterial occlusive disease in the affected limb. GLASS integrates the complexity of disease along a selected target artery path (TAP) from groin to foot. GLASS stages (1-3) are designed to correlate with immediate technical success and 12-month limb-based patency (LBP) following peripheral vascular 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.”
Beyond improving patient care, identifying key research priorities is an important secondary goal for the guideline. Thus, each section includes such priorities and where efforts and resources should be focused to improve patient care and advance the science.
Read the new guideline at vsweb.org/CLTIGuideline.