TY - JOUR
T1 - Global vascular guidelines on the management of chronic limb-threatening ischemia
AU - GVG Writing Group Joint guidelines of the Society for Vascular Surgery
AU - European Society for Vascular Surgery
AU - World Federation of Vascular Societies
AU - Conte, Michael S.
AU - Bradbury, Andrew W.
AU - Kolh, Philippe
AU - White, John V.
AU - Dick, Florian
AU - Fitridge, Robert
AU - Mills, Joseph L.
AU - Ricco, Jean Baptiste
AU - Suresh, Kalkunte R.
AU - Murad, M. Hassan
AU - Forbes, Thomas L.
AU - AbuRahma, Ali
AU - Anankwah, Kwame
AU - Barshes, Neal
AU - Bush, Ruth
AU - Dalman, Ronald L.
AU - Davies, Mark
AU - Farber, Alik
AU - Hingorani, Anil
AU - Malas, Mahmoud
AU - Mondy, J. Sheppard
AU - Rzucidlo, Eva
AU - Schermerhorn, Marc
AU - de Borst, Gert Jan
AU - van den Berg, Jos
AU - Bastos Goncalves, Frederico
AU - Kakkos, Stavros
AU - Koncar, Igor
AU - Lindholt, Jes
AU - Sillesen, Henrik
AU - Muñoz, Alberto
AU - Thiruvengadam, Vidyasagaran
AU - Björck, Martin
AU - Subramaniam, Peter
AU - Rajaruthnam, P.
AU - Bedi, Varinder
AU - Mulaudzi, Thanyani
AU - Komori, Kimihiro
AU - Vidyasagaran, T.
AU - Azuma, Nobuyoshi
AU - Nicholas Wolfe, John Henry
AU - Wolfe, John
AU - Jawien, Arkadiusz
AU - Mutirangura, Pramook
AU - Bourke, Bernie
AU - Balcazar, Alvaro
AU - Paolini, Juan Esteban
AU - Cavaye, Douglas
AU - de Luccia, Nelson
AU - Diamant, Marcelo
N1 - Publisher Copyright:
© 2019 Society for Vascular Surgery and European Society for Vascular Surgery
PY - 2019/6
Y1 - 2019/6
N2 - Chronic limb-threatening ischemia (CLTI)is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG)are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD)in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI)is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR)hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP)and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen)has not been established. Regenerative medicine approaches (eg, cell, gene therapies)for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
AB - Chronic limb-threatening ischemia (CLTI)is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG)are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD)in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI)is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR)hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP)and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen)has not been established. Regenerative medicine approaches (eg, cell, gene therapies)for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
KW - Bypass surgery
KW - Chronic limb-threatening ischemia
KW - Critical limb ischemia
KW - Diabetes
KW - Endovascular intervention
KW - Evidence-based medicine
KW - Foot ulcer
KW - Peripheral artery disease
KW - Practice guideline
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U2 - 10.1016/j.jvs.2019.02.016
DO - 10.1016/j.jvs.2019.02.016
M3 - Article
C2 - 31182334
AN - SCOPUS:85065614180
SN - 0741-5214
VL - 69
SP - 3S-125S.e40
JO - Journal of vascular surgery
JF - Journal of vascular surgery
IS - 6
ER -