A growing, but poorly defined subset of patients with chronic limb-threatening ischemia (CLTI) have “no option” for revascularization. One notable subgroup includes patients with severe ischemia and advanced pedal artery occlusive disease, termed “desert foot,” who are at high risk for major amputation due to a lack of conventional revascularization options. Although new therapies are being developed for no-option patients with desert foot anatomy, this subgroup and the broader group of no-option patients are not well defined, limiting the ability to evaluate outcomes. Based on a systematic review, a classification of the no-option CLTI patient was constructed for use in clinical practice and studies. Several no-option conditions were identified, including type I—severe and pedal occlusive disease (desert foot anatomy) for which there is no accepted method of repair; type II—lack of suitable venous conduit for bypass in the setting of an acceptable target for bypass; type III—extensive tissue loss with exposure of vital structures that renders salvage impossible; type IV—advanced medical comorbidities for which available revascularization options would pose a prohibitive risk; and type V—presence of a nonfunctional limb. While type I and type II patients may have no option for revascularization, type III and type V patients have wounds, infection, comorbidities, or functional status that may leave them with few options for revascularization. As treatment strategies continue to evolve and novel methods of revascularization are developed, the ability to identify no-option patients in a standardized fashion will aid in treatment selection and assessment of outcomes.

INT would have a longer DI time. Smoking status and the prescription of OMT, cilostazol, and a high-dose statin were compared among the quartiles using one-way analysis of variance.Results: A total 25,737 patients at 130 centers were diagnosed with claudication. During follow-up, 9052 patients (35.2%) at 127 centers underwent intervention: 14.2% of the interventions had occurred #30 days from diagnosis, 32.9% at #90 days, and 53.1% at #180 days. The median DI time and %INT varied significantly between center quartiles (P < .001 for both). However, medical management was uniform across all quartiles, with w65% of patients prescribed OMT (P ¼ .38) and w50% active smokers at the time of intervention (P ¼ .11; Table ). As hypothesized, an inverse relationship was found between the %INT and the median DI time (Spearman coefficient, À0.47; P < .001; Fig).Conclusions: We found significant variability in the adherence to guideline recommended management of claudication within the VHA system. Opportunity for quality improvement exists to standardize medical and surgical treatment algorithms. Further research is necessary to ascertain how early intervention affects limb outcomes such as reintervention and amputation.