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Chronic limb-threatening ischemia

What's new

Updated 2024 ACC/AHA guidelines for the diagnosis and management of chronic limb-threatening ischemia.

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 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.
E
Use an integrated threatened limb classification system, such as the WIfI, to stage all patients with CLTI being candidates for limb salvage.
B
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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.
E
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  • Perfusion testing

  • Diagnostic imaging

Medical management

General principles: as per AACVPR/ABC/ACC/AHA/APMA/SCAI/SIR/SVM/SVN/SVS/VESS 2024 guidelines, evaluate and provide comprehensive care by a multispecialty care team to patients with CLTI, with goals of complete wound healing, minimizing tissue loss, and preservation of ambulatory status.
B

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  • Prostanoids

  • Vasoactive agents

  • Angiogenic growth factors

  • Stem cell/gene therapy

  • 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.
A

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  • Intermittent pneumatic compression therapy

Therapeutic procedures

Indications for revascularization: as per SVS 2019 guidelines, perform revascularization in all average-risk patients with advanced limb-threatening conditions (WIfI grade 4) and significant perfusion deficits (WIfI grade 2/3).
B
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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 SVS 2019 guidelines, estimate periprocedural risk and life expectancy in patients with CLTI being candidates for revascularization.
B

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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.
B

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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.
B

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  • Serial clinical assessment

  • Serial imaging assessment

  • 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