SVS Announces New Global Guideline on Chronic Limb-Threatening Ischemia
June 1, 2019—The Society for Vascular Surgery (SVS) announced that a global guideline on managing chronic limb-threatening ischemia (CLTI) was published as a supplement to the June edition of Journal of Vascular Surgery (2019:69;Supplement3S–125S). It was first available online at vsweb.org/CLTIGuideline.
As noted in the announcement, which first appeared in SVS's Vascular Specialist, vascular experts from around the world have researched and worked for 4 years to create this far-reaching guideline with 113 specific recommendations. Contributors included approximately 60 experts from six continents who represented all specialties treating CLTI.
The writing group was led by three coeditors: Michael Conte, MD, from the SVS; Philippe Kohl, MD, from the European Society for Vascular Surgery; and Andrew Bradbury, MD, from the World Federation of Vascular Societies.
A major change is the adoption of "CLTI" to replace “critical limb ischemia (CLI).” The document states that the term CLI is “outdated and fails to encompass the full spectrum” of patients evaluated and treated for limb-threatening ischemia.
According to SVS, the guideline creates a new conceptual framework for treating CLTI, the end-stage of peripheral artery disease that is a problem of increasing prevalence and higher health care costs worldwide. The document encompasses nomenclature, disease staging, and a platform for evidence-based revascularization that will allow for future evolution and quality improvement in the field.
Beyond improving patient care, identifying key research priorities is an important secondary goal for the guideline, with each section including such priorities and where efforts and resources should be focused to improve patient care and advance the science.An extensive evidence review was directed by a methodologist to support the writing group’s work to produce a unique practice guideline, reflecting the spectrum of the disease and approaches seen worldwide, noted Dr. Conte in the SVS announcement.
As outlined by SVS, the guideline's major recommendations encompass the need for comprehensive assessments in patients with suspected CLTI, optimal medical therapy including a variety of treatments for CLTI patients, and prompt and effective revascularization for patients with advanced ischemia and limb threat. Also, it highlights the importance of an individualized approach to improve patient care and reduce limb loss.
SVS advised that significant new changes in the guideline include:
- Staging Limb Threat and Anatomic Complexity: WIfI and GLASS. The guideline endorses the SVS Threatened Limb Classification System based on grading Wound, Ischemia, and foot Infection (WIfI) in the affected limb. It introduces the Global Limb Anatomic Staging System (GLASS) to stratify the patterns of arterial occlusive disease in the affected limb. GLASS integrates the complexity of disease along a selected target artery path from groin to foot. GLASS stages (1, 2, 3) are designed to correlate with immediate technical success and 12-month limb-based patency after peripheral vascular intervention.
- Decision-Making: Have a PLAN. Dr. Conte explained in Vascular Specialist, “Perhaps most notably, the guideline supports a structured approach to decision-making regarding revascularization based on patient risk, limb severity, and anatomic complexity (PLAN), in that order of priority. The guideline seeks to provide a new foundation for practice but also for data collection to support evidenced-based revascularization in CLTI.”