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Chronic limb-threatening ischemia

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Updated 2024 ESC guidelines for the diagnosis and management of chronic limb-threatening ischemia.

Background

Overview

Definition
CLTI, also known as critical limb ischemia, is a severe form of PAD characterized by ischemia and tissue necrosis due to inadequate blood flow to the extremities.
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Pathophysiology
The pathophysiology of CLTI primarily involves inadequate blood supply to the limb tissues due to atherosclerosis, thrombosis, or embolism, leading to tissue hypoxia and ischemia.
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Epidemiology
The annual incidence of CLTI is estimated at 36.2 per 100,000 population, with rates as high as 330 per 100,000 population in the elderly.
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Risk factors
Risk factors for CLTI include advanced age, diabetes, smoking, hypertension, renal failure, HF, history of stroke, prior open revascularization, and multiple reinterventions after lower extremity revascularization for claudication.
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Disease course
CLTI is characterized by non-healing ulcers, gangrene, and severe limb pain, often at rest.
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Prognosis and risk of recurrence
The prognosis of CLTI is often poor, with high mortality rates and a significant risk of major amputation. The risk of major amputation (above the ankle) or death, or both, ranges between 20% and 40% at 1 year in untreated cases.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of chronic limb-threatening ischemia are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2024), the Vascular and Endovascular Surgery Society (VESS/SCAI/ABC/SVM/SVN/SVS/AHA/AACVPR/ACC/APMA/SIR 2024), the Canadian Cardiovascular Society (CCS 2022), the Society for Vascular Surgery (SVS 2019), and the European Society of Cardiology (ESC/ESVS 2018).
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Classification and risk stratification

Classification and staging
As per SVS 2019 guidelines:
Use an integrated, limb-based anatomic staging system, such as the GLASS, to define complexity of a preferred target artery path and to facilitate evidence-based revascularization in patients with CLTI.
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Use an integrated threatened limb classification system, such as the WIfI, to stage all patients with CLTI being candidates for limb salvage.
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  • Risk stratification

Diagnostic investigations

History and physical examination: as per SVS 2019 guidelines, elicit a detailed history to determine symptoms, past medical history, and cardiovascular risk factors in all patients with suspected CLTI.
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  • Perfusion testing

  • Diagnostic imaging

Medical management

General principles
As per ESC 2024 guidelines:
Recognize early signs of CLTI and refer to the vascular team for limb salvage.
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Manage patients with CLTI by a vascular team.
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  • Prostanoids

  • Vasoactive agents

  • Angiogenic growth factors

  • Antibiotics

  • Antithrombotic therapy

  • Statin therapy

  • Management of pain

  • Management of comorbidities

Nonpharmacologic interventions

Smoking cessation: as per SVS 2019 guidelines, offer smoking cessation interventions (pharmacotherapy, counseling, or behavior modification therapy) in all patients with CLTI smoking or using tobacco products.
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  • Footwear

  • Intermittent pneumatic compression therapy

  • Exercise therapy

Therapeutic procedures

Indications for revascularization
As per ESC 2024 guidelines:
Perform revascularization for limb salvage in patients with CLTI.
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Perform revascularization as soon as possible in patients with CLTI.
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  • Choice of revascularization procedure

  • Endovascular revascularization (indications)

  • Endovascular revascularization (technical considerations)

  • Balloon angioplasty

  • Venous arterialization

  • Spinal cord stimulation

  • Lumbar sympathectomy

  • Hyperbaric oxygen therapy

Perioperative care

Periprocedural risk assessment: as per ESC 2024 guidelines, obtain an individual risk assessment (weighing the patients individual procedural risk of endovascular versus surgical revascularization) by a multidisciplinary vascular team.
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  • Postprocedural restaging

Surgical interventions

Wound care: as per AACVPR/ABC/ACC/AHA/APMA/SCAI/SIR/SVM/SVN/SVS/VESS 2024 guidelines, provide wound care after revascularization in patients with CLTI with nonhealing wounds to optimize the wound healing environment with the goal of complete wound healing.
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  • Surgical debridement

  • Surgical revascularization (indications)

  • Surgical revascularization (choice of conduit)

  • Surgical revascularization (perioperative imaging)

  • Amputation (evaluation)

  • Amputation (primary amputation)

  • Amputation (secondary amputation)

  • Amputation (technical considerations)

  • Amputation (follow-up)

Follow-up and surveillance

Indications for specialist referral: as per CCS 2022 guidelines, refer all patients with CLTI urgently to vascular specialists for consideration of revascularization.
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  • Clinical follow-up

  • Imaging follow-up

  • Post-revascularization care (general principles)

  • Post-revascularization care (wound care)

  • Post-revascularization care (dual antiplatelet therapy)

  • Post-revascularization care (hyperbaric oxygen therapy)

  • Management of restenosis