Chronic Limb-Threatening Ischemia Management (GVG 2019)

Algorithm Steps

1. ▶

   Start

   Suspected CLTI

   Rest pain, non-healing ulcer, or gangrene with evidence of PAD

   1. ●

      Action

      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
      1. ●

         Action

         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
         1. ◆

            Decision

            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
            1. ◆

               Decision

               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
               1. ●

                  Action

                  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
                  1. ●

                     Action

                     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
                     1. ●

                        Action

                        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
                        1. ✓

                           Outcome

                           Limb Salvage

                           1-year limb salvage 70-80% with revascularization

                        2. ✓

                           Outcome

                           Wound Healing

                           Complete healing in 50-60% at 1 year; tissue loss may require minor amputation

                        3. ✓

                           Outcome

                           Major Amputation

                           20-30% at 1 year despite therapy; mortality 20-30% at 1 year

                  2. ●

                     Action

                     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)
               2. ●

                  Action

                  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
               3. ●

                  Action

                  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
               4. ⚠

                  Warning

                  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
      2. ●

         Action

         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
      3. ●

         Action

         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