Suspected CLTI
Rest pain, non-healing ulcer, or gangrene with evidence of PAD
All Pathways
Vascular SurgeryManagement
Chronic Limb-Threatening Ischemia Management (GVG 2019)
Chronic Limb-Threatening Ischemia Management (GVG 2019): Suspected CLTI → Clinical Diagnosis → Hemodynamic Assessment → PLAN Framework → Revascularizati...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action Clinical Diagnosis
CLTI = ischemic rest pain or tissue loss + objective evidence of PAD
- Ischemic rest pain: night pain, hanging leg over bed
- Tissue loss: non-healing ulcer, gangrene
- Duration >2 weeks
- Objective evidence: ABI <0.4, toe pressure <30 mmHg, TcPO2 <30 mmHg
03Action Hemodynamic Assessment
Objective ischemia evaluation
- ABI: <0.4 = severe ischemia
- Toe-brachial index (TBI): <0.3 = severe
- Toe pressure: <30 mmHg
- TcPO2: <30 mmHg
- Note: ABI may be falsely elevated in diabetics
04Decision PLAN Framework
Patient risk, Limb staging, ANatomic pattern
- P: Patient risk (comorbidities, life expectancy, ambulatory status)
- L: Limb staging (WIfI stage, functional status)
- AN: Anatomic pattern (GLASS, target vessel, conduit)
- Guides treatment intensity
05Decision Revascularization Beneficial?
Based on PLAN assessment
- High benefit: WIfI 2-4, adequate target, reasonable risk
- Low benefit: limited life expectancy, non-ambulatory, no target
- Consider primary amputation if patient/limb factors unfavorable
06Action Endovascular-First Strategy
Preferred for many patients
- Lower perioperative risk
- PTA ± stenting
- Drug-coated balloons for femoropopliteal
- Goal: in-line flow to foot
- May need staged procedures
07Action Comprehensive Wound Care
Essential alongside revascularization
- Debridement of non-viable tissue
- Offloading (total contact cast, removable boot)
- Moist wound healing environment
- Infection control (IV antibiotics if needed)
- Multidisciplinary limb salvage team
08Action Post-Revascularization Surveillance
Graft/stent surveillance program
- Duplex surveillance: 1, 3, 6, 12 months then annually
- Detect stenosis before occlusion
- ABI monitoring
- Wound healing assessment
- Repeat intervention for failing graft/stent
09Outcome Limb Salvage
1-year limb salvage 70-80% with revascularization
10Outcome Wound Healing
Complete healing in 50-60% at 1 year; tissue loss may require minor amputation
11Outcome Major Amputation
20-30% at 1 year despite therapy; mortality 20-30% at 1 year
12Action Medical Optimization
Risk factor control essential
- Antiplatelet therapy (aspirin ± clopidogrel post-intervention)
- High-intensity statin
- Diabetes control (HbA1c target individualized)
- Blood pressure control
- Smoking cessation (critical)
- Path rejoins step 08Shared downstream outcome
13Action Open Surgical Bypass
Best for suitable anatomy and conduit
- Single-segment great saphenous vein preferred
- Femoropopliteal or femorotibial bypass
- Superior durability vs endovascular for GLASS P2/FP2C/D
- Requires adequate conduit and target
- Higher perioperative risk
- Path rejoins step 07Shared downstream outcome
- Path rejoins step 12Shared downstream outcome
14Action Hybrid Approach
Combined open and endovascular
- Inflow lesion: endovascular
- Outflow: surgical bypass
- Staged or simultaneous
- Individualized based on anatomy
- Common: iliac PTA + femoral-popliteal bypass
- Path rejoins step 07Shared downstream outcome
15Warning Primary Amputation
When revascularization not beneficial
- Extensive gangrene/necrosis beyond salvage
- Non-ambulatory with fixed flexion contracture
- Limited life expectancy (comfort focus)
- No revascularization target
- Patient preference after informed discussion
- Path rejoins step 11Shared downstream outcome
16Action WIfI Staging
Wound, Ischemia, foot Infection classification
- W (Wound): 0-3 based on depth, extent, gangrene
- I (Ischemia): 0-3 based on ABI, ankle/toe pressure
- fI (foot Infection): 0-3 IDSA/IWGDF criteria
- Predicts amputation risk and revascularization benefit
- Path rejoins step 04Shared downstream outcome
17Action Anatomic Imaging
Define disease extent for revascularization planning
- CTA or MRA (preferred non-invasive)
- Duplex ultrasound (adjunct)
- Catheter angiography if intervention planned
- GLASS classification: femoropopliteal + infrapopliteal patterns
- Assess target vessel for revascularization
- Path rejoins step 04Shared downstream outcome
Guideline Source
Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- CLTI terminology replaced CLI (critical limb ischemia)
- WIfI staging requires wound assessment expertise
- GLASS anatomic classification complex - vascular specialist needed
- Diabetes and renal failure significantly impact outcomes
- Shared decision-making essential given amputation risk
Applicable Regions
USEUGlobal
EU: GVG 2019 developed jointly by SVS, ESVS, WFVS
US: ACC/AHA 2024 PAD guidelines incorporate CLTI management
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Chronic Limb-Threatening Ischemia Management (GVG 2019)?
The Chronic Limb-Threatening Ischemia Management (GVG 2019) is a management clinical algorithm for Vascular Surgery. It provides a structured decision tree to guide clinical decision-making, based on Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.
What guideline is the Chronic Limb-Threatening Ischemia Management (GVG 2019) based on?
This algorithm is based on Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia (DOI: 10.1016/j.ejvs.2019.05.006).
What are the limitations of the Chronic Limb-Threatening Ischemia Management (GVG 2019)?
Known limitations include: CLTI terminology replaced CLI (critical limb ischemia); WIfI staging requires wound assessment expertise; GLASS anatomic classification complex - vascular specialist needed; Diabetes and renal failure significantly impact outcomes; Shared decision-making essential given amputation risk. Individual patient factors may require deviation from these recommendations.
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