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Chronic limb-threatening ischemia

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 Canadian Cardiovascular Society (CCS 2022), the Society for Vascular Surgery (SVS 2019), the European Society of Cardiology (ESC/ESVS 2018), and the American Heart Association (AHA/ACC 2017).


1.Classification and risk stratification

Classification and staging
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.
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

2.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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  • Diagnostic imaging

3.Medical management

Prostanoids: as per SVS 2019 guidelines, do not use prostanoids for limb salvage in patients with CLTI. Consider offering prostanoids in selected patients with rest pain or minor tissue loss, and if revascularization is not possible.

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  • Vasoactive agents

  • Angiogenic growth factors

  • Gene therapy

  • Antithrombotic therapy

  • Statin therapy

  • Management of pain

  • Management of comorbidities

4.Nonpharmacologic interventions

Smoking cessation: offer smoking cessation interventions (pharmacotherapy, counseling, or behavior modification therapy) in all patients with CLTI smoking or using tobacco products.

5.Therapeutic procedures

Indications for revascularization: as per CCS 2022 guidelines, consider performing endovascular, open or hybrid revascularization on the basis of the anatomical pattern of disease, degree of ischemia, expected durability of the procedure, perioperative risk and patient life expectancy in patients with CLTI.

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  • Endovascular revascularization

  • Balloon angioplasty

  • Intermittent pneumatic compression therapy

  • Spinal cord stimulation

  • Lumbar sympathectomy

  • Hyperbaric oxygen therapy

6.Perioperative care

Periprocedural risk assessment: estimate periprocedural risk and life expectancy in patients with CLTI being candidates for revascularization.

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  • Postprocedural restaging

7.Surgical interventions

Wound care: as per SVS 2019 guidelines, provide optimal wound care until the lower extremity wound is completely healed or the patient undergoes amputation.

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  • Surgical debridement

  • Surgical revascularization

  • Amputation

8.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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  • Serial clinical assessment

  • Serial imaging assessment

  • Post-revascularization care (general principles)

  • Post-revascularization care (foot care)

  • Post-revascularization care (dual antiplatelet therapy)

  • Management of restenosis