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

, , , Michael S. Conte (Lead / Corresponding author), Andrew W. Bradbury, Philippe Kolh, John V. White, Florian Dick, Robert Fitridge, Joseph L. Mills, Jean Baptiste Ricco, Kalkunte R. Suresh, M. Hassan Murad, Victor Aboyans, Murat Aksoy, Vlad Adrian Alexandrescu, David Armstrong, Nobuyoshi Azuma, Jill Belch, Michel BergoeingMartin Bjorck, Nabil Chakfé, Stephen Cheng, Joseph Dawson, Eike S. Debus, Andrew Dueck, Susan Duval, Hans H. Eckstein, Roberto Ferraresi, Raghvinder Gambhir, Mauro Garguilo, Patrick Geraghty, Steve Goode, Bruce Gray, Wei Guo, Prem C. Gupta, Robert Hinchliffe, Prasad Jetty, Kimihiro Komori, Lawrence Lavery, Wei Liang, Robert Lookstein, Matthew Menard, Sanjay Misra, Tetsuro Miyata, Greg Moneta, Jose A. Munoa Prado, Alberto Munoz, Juan E. Paolini, Manesh Patel, Frank Pomposelli, Richard Powell, Peter Robless, Lee Rogers, Andres Schanzer, Peter Schneider, Spence Taylor, Melina Vega De Ceniga, Martin Veller, Frank Vermassen, Jinsong Wang, Shenming Wang

Research output: Contribution to journalArticlepeer-review

753 Citations (Scopus)
517 Downloads (Pure)


Chronic limb-threatening ischemia (CLTI)is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG)are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD)in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI)is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR)hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP)and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen)has not been established. Regenerative medicine approaches (eg, cell, gene therapies)for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Original languageEnglish
Pages (from-to)3S-125S.e40
JournalJournal of Vascular Surgery
Issue number6
Early online date28 May 2019
Publication statusPublished - Jun 2019


  • Bypass surgery
  • Chronic limb-threatening ischemia
  • Critical limb ischemia
  • Diabetes
  • Endovascular intervention
  • Evidence-based medicine
  • Foot ulcer
  • Peripheral artery disease
  • Practice guideline

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine


Dive into the research topics of 'Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia'. Together they form a unique fingerprint.

Cite this