Key Points
2
➤ Chronic limb-threatening ischemia (CLTI) represents the end stage
of peripheral artery disease (PAD), a problem of growing prevalence
and increased health care costs around the globe. CLTI is a highly
morbid disease, incurring significant mortality, limb loss, pain, and
diminished health-related quality of life.
➤ Vascular specialists evaluate patients with CLTI across a broad
range of disease severity. This guideline promotes the use of the
SVS Threatened Limb Classification System (WIfI) for clinical staging
and proposes a new limb-based anatomic staging system for the
complexity of arterial occlusive disease.
➤ Objective measurement of perfusion (e.g. ankle, toe pressures) is
essential for accurate staging of CLTI. The presence and degree
of ischemia is an important determinant of risk of limb loss and
treatment approach.
➤ Optimal medical therapy aims to reduce mortality and major adverse
cardiovascular events and may have benefits in reducing limb-related
events as well. All vascular specialists treating CLTI should assess
and provide evidence-based recommendations on lifestyle and
medical therapies.
➤ The goals of limb treatment in CLTI are to maintain function, reduce
pain, and heal wounds. Selection of appropriate candidates for
revascularization depends on careful assessment of patient risk,
functional status, clinical severity and salvageability of the affected
foot.
➤ Structured decision-making in CLTI follows the PLAN concept,
assessing (in order) Patient risk, Limb stage, and ANatomic
complexity of disease to define the best approach to revascularization
for individual patients.
➤ The effectiveness of non-revascularization treatments for CLTI
including pharmacotherapies, hyperbaric oxygen, pneumatic
compression, spinal cord stimulation, cell and gene therapies appears
limited and further research is needed to establish their role, if any.
➤ Patients with CLTI require long-term surveillance for disease
recurrence/progression and should be maintained on appropriate
vasculo-protective medications.
➤ Future clinical trials in CLTI should incorporate stratification by
disease stage, meaningful clinical and patient-reported outcomes,
and have appropriate follow-up duration to better define clinical
effectiveness.