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New guideline offers tips for diagnosis, treatment of chronic limb-threatening ischemia
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A new multisociety guideline clarifies how to diagnose chronic limb-threatening ischemia, or CLTI, and emphasizes offering patients optimal medical therapy and offers a new classification system to determine the best revascularization strategy for a patient.
The guideline, written by the Society for Vascular Surgery, the European Society for Vascular Surgery and the World Federation of Vascular Societies and endorsed by nine other societies, was published in the Journal of Vascular Surgery.
“This guideline provides a new foundation for describing and treating CLTI, an escalating public health problem around the world that involves a broad array of health professionals,” Michael S. Conte, MD, co-editor of the document, co-director of the University of California, San Francisco (UCSF) Heart and Vascular Center and chief of UCSF’s Division of Vascular & Endovascular Surgery, said in a press release. “By improving the staging of CLTI, we believe that optimal care pathways can be defined and based on more accurate clinical and epidemiologic evidence going forward.”
Change in nomenclature
The document recommends using the term CLTI instead of critical limb ischemia because CLI “implies threshold values of impaired perfusion rather than a continuum,” the authors wrote.
The authors defined CLTI as peripheral artery disease in combination with rest pain, gangrene or a lower limb ulceration of more than 2 weeks in duration and recommended that patients with suspected CLTI be referred to a vascular specialist immediately.
The document endorsed the SVS Wound, Ischemia, and foot Infection (WIfI) classification system and also endorsed objective hemodynamic measurement, particularly toe pressure, to diagnose the condition.
Medical therapy and preventive care were also endorsed. “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,” Conte and colleagues wrote.
Evidence-based revascularization should be based on patient risk, limb severity and anatomic complexity, according to the authors.
The panel also devised the Global Anatomic Staging System (GLASS) to define a preferred target artery path and to estimate limb-based patency, which stratifies patients into three categories of anatomic complexity.
Regenerative medicine treatment approaches should at this time be restricted to well-controlled clinical trials, and nonrevascularization therapies such as spinal stimulation, pneumatic compression, prostanoids and hyperbaric oxygen do not yet have enough evidence to support them, according to the authors.
“With the continuous evolution of vascular technology, we must remain focused on the primary goals of treatment, in contradistinction to a lesion-centric emphasis on technical success,” Conte said in the release.
Consider many approaches
“The old adage ‘when your only tool is a hammer, the whole world looks like a nail’ certainly applies to the management of CLTI,” Peter F. Lawrence, MD, chief of vascular surgery at Ronald Reagan UCLA Medical Center, and Peter Gloviczki, MD, FACS, Joe M. and Ruth Roberts Professor of Surgery (emeritus) of the Division of Vascular and Endovascular Surgery at Mayo Clinic, wrote in a related editorial. “Considering only one approach may reduce the likelihood of successful treatment and it may even expose patients to ineffective or inappropriately invasive procedures. Having an autogenous saphenous vein available favors surgical bypass in advanced CLTI, while endovascular interventions are preferred for high-risk patients with less complex anatomy.” – by Erik Swain
Disclosure s : The authors and editorial writers report no relevant financial disclosures.
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