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Chronic Limb-Threatening Ischemia

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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.

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