What is the management approach for Chronic Limb-Threatening Ischemia (CLTI)?

Management of Chronic Limb-Threatening Ischemia (CLTI)

Early recognition of CLTI and immediate referral to a vascular team are essential for limb salvage, with revascularization recommended as soon as possible to reduce mortality and amputation risk. 1

Diagnosis and Initial Assessment

• CLTI is defined as peripheral artery disease (PAD) combined with:

  • Rest pain
  • Gangrene
  • Lower limb ulceration >2 weeks duration 2

• Initial evaluation should include:

  • Duplex ultrasound (DUS) as first-line imaging 1
  • Objective hemodynamic testing (toe pressures preferred) 2
  • Assessment using the Society for Vascular Surgery Threatened Limb Classification system (WIfI: Wounds, Ischemia, foot Infection) 2

Revascularization Strategy

Decision-Making Framework

1. Patient Risk Assessment:

   • Evaluate procedural and 2-year all-cause mortality risk 2
   • Categorize as average-risk or high-risk

2. Limb Severity Assessment:

   • Evaluate degree of tissue loss, infection, and ischemia
   • More severe limb threat may favor surgical approach

3. Anatomic Complexity Assessment:

   • Define preferred target artery path
   • Estimate limb-based patency
   • Classify into three stages of complexity 2

4. Vein Conduit Availability:

   • Presence of adequate autologous vein is critical for bypass decision-making 3, 4

Specific Revascularization Recommendations

• For patients with adequate great saphenous vein:

  • Surgical bypass is superior to endovascular therapy for reducing major adverse limb events and death (42.6% vs 57.4%) 4
  • Autologous veins are the preferred conduit for infra-inguinal bypass surgery 3, 1

• For patients without adequate saphenous vein:

  • Endovascular therapy may be considered as first-line treatment 3, 1
  • Outcomes between surgical and endovascular approaches are similar (42.8% vs 47.7%) 4

• For multilevel disease:

  • Eliminate inflow obstructions when treating downstream lesions 3, 1

• For femoro-popliteal lesions:

  • Drug-eluting treatment should be considered as first-choice strategy 3, 1

Post-Revascularization Care

• Antithrombotic Therapy:

  • Single antiplatelet therapy with aspirin (75-160mg) or clopidogrel (75mg) is recommended 3
  • Long-term dual antiplatelet therapy is not recommended 3
  • Dual antiplatelet therapy is commonly used after endovascular interventions (79% of clinicians) 5

• Follow-up Protocol:

  • Regular follow-up is mandatory after revascularization 3, 1
  • Assess clinical, hemodynamic and functional status, limb symptoms, treatment adherence, and cardiovascular risk factors 3, 1
  • At least annual follow-up for all PAD patients 1

Additional Management Considerations

• Medical Therapy:

  • Optimize antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents 2
  • Smoking cessation counseling 2

• Wound Care:

  • Offloading mechanical tissue stress for ulcer healing 3
  • Adequate debridement and infection control 6

• Exercise Therapy:

  • Lower-limb exercise training is NOT recommended in patients with CLTI and wounds 3, 1

Common Pitfalls and Caveats

• Delayed Recognition and Referral:

  • CLTI is often recognized late, increasing amputation risk 7
  • Urgent referral to vascular specialists is critical 3, 1

• Underestimation of Bleeding Risk:

  • Bleeding risk assessment is often not standardized in antithrombotic management 5

• Inconsistent Antithrombotic Protocols:

  • Only 36% of centers have dedicated protocols for antithrombotic therapy after revascularization 5
  • Practices vary widely across countries and specialties

• Hub vs. Spoke Disparities:

  • Patients treated at non-vascular hub centers may experience delays in care 7

The BEST-CLI trial provides the strongest evidence that surgical bypass with adequate autologous vein is superior to endovascular therapy for CLTI patients, while endovascular approaches are reasonable first-line options when adequate vein is unavailable 4.