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Cited by 2,015Peripheral Artery Disease ManagementVascular Procedures and ComplicationsAbdominal vascular conditions and treatments

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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 Sebastian, Dueck, Andrew, Duval, Susan, Eckstein, Hans Henning, Ferraresi, Roberto, Gambhir, Raghvinder, Gargiulo, Mauro, Geraghty, Patrick, Goode, Steve, Gray, Bruce, Guo, Wei, Gupta, Prem Chand, Hinchliffe, Robert, Jetty, Prasad, Komori, Kimihiro, Lavery, Lawrence, Liang, Wei, Lookstein, Robert, Menard, Matthew, Misra, Sanjay, Miyata, Tetsuro, Moneta, Greg, Prado, Jose Antonio Munoa, Munoz, Alberto, Paolini, Juan Esteban, Patel, Manesh, Pomposelli, Frank, Powell, Richard, Robless, Peter, Rogers, Lee, Schanzer, Andres, Schneider, Peter, Taylor, Spence, Vega De Ceniga, Melina, Veller, Martin, Vermassen, Frank, Wang, Jinsong, Wang, Shenming·2019·Journal of Vascular Surgery
DOI 10.1016/j.jvs.2019.02.016PMC PMC8365864
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Abstract

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., Prado, J. A. M., Munoz, A., Paolini, J. E., Patel, M., Pomposelli, F., Powell, R., Robless, P., Rogers, L., Schanzer, A., Schneider, P., Taylor, S., Vega De Ceniga, M., 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)
  • Kantonsspital St. Gallen (CH)
  • The University of Adelaide (AU)
  • Baylor College of Medicine (US)
  • Université de Poitiers (FR)
  • Mayo Clinic (US)
  • University of Dundee (GB)
Corresponding author
Conte, Michael S.
ORCID
Venue
Journal of Vascular Surgery
Publisher
Elsevier BV
Published
2019-06
Volume
69
Issue
6
Pages
3S-125S.e40
ISSN
0741-5214 (ISSN-L)
DOI
10.1016/j.jvs.2019.02.016
PMC
PMC8365864
OpenAlex
W2947332499
Cited by
2,015
References
716
Citations by year
2026: 247 · 2025: 267 · 2024: 320 · 2023: 342 · 2022: 294 · 2021: 279 · 2020: 216 · 2019: 47
FWCI
199.72
Type
journal article
Language
en
Update notices
erratum (2019-08-01)
Open access
Licence
Locations
  • Journal of Vascular Surgery (publishedVersion)
  • PubMed (publishedVersion)
  • Pure Amsterdam UMC (publishedVersion)
  • Bristol Research (University of Bristol) (publishedVersion, cc-by-nc-nd)
  • PubMed Central (acceptedVersion)
  • Archivio istituzionale della ricerca (Alma Mater Studiorum Università di Bologna) (submittedVersion)
  • Discovery Research Portal (University of Dundee) (submittedVersion, cc-by-nc-nd)
  • mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
  • Open Repository and Bibliography (University of Liège) (submittedVersion, other-oa)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (submittedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
Funders
  • National Institutes of Health (UL1TR001855)
  • National Heart, Lung, and Blood Institute (R01HL098967)
  • National Institute of Diabetes and Digestive and Kidney Diseases (R44DK102244, 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 › Surgery › Abdominal vascular conditions and treatments
Keywords
critical limb ischemia, peripheral arterial disease, revascularization, WIfI classification, toe pressure, vein bypass, endovascular intervention, optimal medical therapy, regenerative medicine, amputation prevention
MeSH terms
Cardiology, Chronic Disease, Heart Function Tests, Humans, Ischemia, Terminology as Topic, Predictive Value of Tests, Risk Factors, Treatment Outcome, Evidence-Based Medicine, Consensus, Cardiac Imaging Techniques, Peripheral Arterial Disease

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