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Cited by 1,582Peripheral Artery Disease ManagementVascular Procedures and ComplicationsDiabetic Foot Ulcer Assessment and Management

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Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

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Conte, Michael S., Bradbury, Andrew W., Kolh, Philippe, White, John V., Dick, Florian, Fitridge, Robert, Mills, Joseph L., Ricco, Jean-Baptiste, Suresh, Kalkunte R., Murad, M. Hassan, Aboyans, Victor, Aksoy, Murat, Alexandrescu, Vlad-Adrian, Armstrong, David, Azuma, Nobuyoshi, Belch, Jill, Bergoeing, Michel, Bjorck, Martin, Chakfé, Nabil, Cheng, Stephen, Dawson, Joseph, Debus, Eike S., Dueck, Andrew, Duval, Susan, Eckstein, Hans H., Ferraresi, Roberto, Gambhir, Raghvinder, Gargiulo, Mauro, Geraghty, Patrick, Goode, Steve, Gray, Bruce, Guo, Wei, Gupta, Prem C., Hinchliffe, Robert, Jetty, Prasad, Komori, Kimihiro, Lavery, Lawrence, Liang, Wei, Lookstein, Robert, Menard, Matthew, Misra, Sanjay, Miyata, Tetsuro, Moneta, Greg, Munoa Prado, Jose A., Munoz, Alberto, Paolini, Juan E., Patel, Manesh, Pomposelli, Frank, Powell, Richard, Robless, Peter, Rogers, Lee, Schanzer, Andres, Schneider, Peter, Taylor, Spence, De Ceniga, Melina V., Veller, Martin, Vermassen, Frank, Wang, Jinsong, Wang, Shenming·2019·European Journal of Vascular and Endovascular Surgery
DOI 10.1016/j.ejvs.2019.05.006PMC PMC8369495
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Abstract

Guideline summary 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.

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Metadata

Authors
Conte, M. S., Bradbury, A. W., Kolh, P., White, J. V., Dick, F., Fitridge, R., Mills, J. L., Ricco, J.-B., Suresh, K. R., Murad, M. H., Aboyans, V., Aksoy, M., Alexandrescu, V.-A., Armstrong, D., Azuma, N., Belch, J., Bergoeing, M., Bjorck, M., Chakfé, N., Cheng, S., Dawson, J., Debus, E. S., Dueck, A., Duval, S., Eckstein, H. H., Ferraresi, R., Gambhir, R., Gargiulo, M., Geraghty, P., Goode, S., Gray, B., Guo, W., Gupta, P. C., Hinchliffe, R., Jetty, P., Komori, K., Lavery, L., Liang, W., Lookstein, R., Menard, M., Misra, S., Miyata, T., Moneta, G., Munoa Prado, J. A., Munoz, A., Paolini, J. E., Patel, M., Pomposelli, F., Powell, R., Robless, P., Rogers, L., Schanzer, A., Schneider, P., Taylor, S., De Ceniga, M. V., Veller, M., Vermassen, F., Wang, J., & Wang, S.
Affiliations
  • University of California, San Francisco (US)
  • University of Birmingham (GB)
  • University of Liège (BE)
  • Advocate Lutheran General Hospital (US)
  • University of Bern (CH)
  • The University of Adelaide (AU)
  • Baylor College of Medicine (US)
  • Université de Poitiers (FR)
  • Mayo Clinic (US)
  • University of Southern California (US)
  • Asahikawa Medical University (JP)
  • University of Dundee (GB)
  • Pontificia Universidad Católica de Chile (CL)
  • Hôpitaux Universitaires de Strasbourg (FR)
  • University of Hong Kong (HK)
  • Royal Adelaide Hospital (AU)
  • Universität Hamburg (DE)
  • Sunnybrook Health Science Centre (CA)
  • University of Minnesota (US)
  • Technical University of Munich (DE)
  • King's College Hospital (GB)
  • University of Bologna (IT)
  • Prisma Health (US)
  • Chinese PLA General Hospital (CN)
  • CARE Hospitals (IN)
  • University of Bristol (GB)
  • University of Ottawa (CA)
  • Nagoya University (JP)
  • The University of Texas Southwestern Medical Center (US)
  • Shanghai Jiao Tong University (CN)
  • Icahn School of Medicine at Mount Sinai (US)
  • Brigham and Women's Hospital (US)
  • Sanno Medical Center (JP)
  • Oregon Health & Science University (US)
  • Universidad de Buenos Aires (AR)
  • Duke University Health System (US)
  • St. Elizabeth's Medical Center (US)
  • Mount Elizabeth Hospital (SG)
  • Kaiser Foundation Hospital (US)
  • University of the Witwatersrand (ZA)
  • Ghent University Hospital (BE)
  • The First Affiliated Hospital, Sun Yat-sen University (CN)
Corresponding author
Conte, Michael S.
ORCID
Venue
European Journal of Vascular and Endovascular Surgery
Publisher
Elsevier BV
Published
2019-07
Volume
58
Issue
1
Pages
S1-S109.e33
ISSN
1078-5884 (ISSN-L)
DOI
10.1016/j.ejvs.2019.05.006
PMC
PMC8369495
OpenAlex
W4239553742
Cited by
1,582
References
700
Citations by year
2026: 266 · 2025: 226 · 2024: 274 · 2023: 214 · 2022: 231 · 2021: 195 · 2020: 144 · 2019: 32
FWCI
143.64
Type
journal article
Language
en
Update notices
erratum (2020-03-01)
Open access
Licence
Locations
  • European Journal of Vascular and Endovascular Surgery (publishedVersion)
  • University of Birmingham Research Portal (University of Birmingham) (publishedVersion, cc-by-nc-nd)
  • Ghent University Academic Bibliography (Ghent University) (submittedVersion)
  • Discovery Research Portal (University of Dundee) (submittedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
  • mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
  • Open Repository and Bibliography (University of Liège) (submittedVersion)
Funders
  • Cook Medical
  • National Institutes of Health (UL1TR001855)
  • Japan Society for the Promotion of Science (17H04290)
  • National Heart, Lung, and Blood Institute (R01HL098967)
  • National Institute of Diabetes and Digestive and Kidney Diseases (R01DK124789)
  • National Center for Advancing Translational Sciences
Topics
  • Health Sciences › Medicine › Surgery › Peripheral Artery Disease Management
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Vascular Procedures and Complications
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetic Foot Ulcer Assessment and Management
Keywords
critical limb ischemia, peripheral arterial disease, revascularization, WIfI classification, toe pressure, risk stratification, vein bypass, endovascular intervention, optimal medical therapy, regenerative medicine, amputation prevention

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