Review of the Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

Abstract

In 2010, it was estimated that more than 200 million people worldwide were living with peripheral arterial disease. Chronic limbthreatening ischemia (CLTI) represents the end stage of peripheral arterial disease, which, left untreated, incurs a risk of major amputation, approaching 25% at 1 year. Despite the global scale and severe clinical consequences of CLTI, it has been poorly defined and variably managed. Prior guidelines, such as the Trans-atlantic Intersociety Consensus Document on the Management of Peripheral Arterial Disease (TASC II), have offered treatment recommendations based on disease anatomy alone. 1 A more contemporary, nuanced definition of the problem and thorough understanding of the state of evidence are required to guide medical treatment, revascularization strategies, and future study. 2 Characteristics of the Guideline SourceThree vascular societies formed the global vascular guideline initiative: the European Society for Vascular Surgery, the Society for Vascular Surgery, and the World Federation of Vascular Societies. The writing group was composed of 58 individuals from 24 countries and multiple medical and surgical specialties. Although the 3 sponsoring societies primarily represent vascular surgeons, these guidelines were endorsed by multiple international groups representing medical and interventional specialties. All funding for the guidelines was from the sponsoring societies. Direct industry funding of the guidelines was prohibited, and industry consultants were ex-cluded from both the writing and reviewing groups. Strict limits were set for contributing authors on industry income during work on the guidelines, and conflicts of interest were reported in detail. An open comment period was observed prior to publication. Evidence BaseAuthors used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methods to rate recommendation strength and quality of evidence. Final grading was determined by the guideline developers and a methodologist. Four systematic reviews were commissioned, subjected to peer review, and published in the Journal of Vascular Surgery, focusing on the natural history of CLTI, 3 nonrevascularization-based treatments, 4 and outcomes associated with revascularization. 5,6 The guidelines were published in the June 2019 issue of the

A systematic review of patient-reported outcome measures patients with chronic limb-threatening ischemia

“…Further, PROMs will be needed when treatments are compared across different groups in clinical trials. [20][21][22][23] Finally, the overall impact of systematic treatment of the comorbidities which often occurs concomitantly with CLTI, such as diabetes and smoking, may have small impact at the individual level. However, when examining small changes in QoL using accurate tools, differences may be detectable in large populations if the measures are precise and reproducible.…”

Predictors of restenosis after popliteal angioplasty in patients with chronic limb threatening ischemia

“…Computed tomographic angiography was done to evaluate patency of the proximal arterial tree, site, character and length of the lesion, presence and severity of calcification and the status of the distal run-off vessels. After CT angiography, the TASC II stage [10] and Global Limb Anatomic Staging System (GLASS) stage [11] were determined for each patient.…”

Pain Management in People with Diabetes-Related Chronic Limb-Threatening Ischemia

“…The treatment for CLTI is aimed at relieving ischemic pain, healing ischemic ulcers, avoiding limb loss, improving life quality, and prolonging survival. For pain management in CLTI, guidelines usually recommend a tiered approach, with a “trade off” between benefits and harms [ 5 , 61 , 62 ]. As no optimal pharmacological therapy has been established, the management of ischemic pain is challenging in patients unsuitable for endovascular intervention or amputation surgery [ 32 ].…”