University of California San Francisco

Global Vascular Guidelines for Chronic Limb-Threatening Ischemia (CLTI) Published by International Team

UCSF Division of Vascular & Endovascular Surgery
June 12, 2019

Conte 27Mar2019 High Res

The Global Vascular Guidelines for the Treatment of Chronic Limb-Threatening Ischemia (CLTI), an initiative to standardize and improve the quality of care of patients with CLTI worldwide, has been published in the Journal of Vascular Surgery (JVS), as a supplement to the June 2019 edition.

The global effort was spearheaded by a trio of internationally renowned vascular surgeons who served as co-editors of the publication: Michael S. Conte, M.D., Professor and Chief of the Division of Vascular & Endovascular Surgery at UCSF,  Andrew W. Bradbury, MD of the University of Birmingham, United Kingdom, and Philippe Kolh, MD of the University Hospital of Liège in Belgium. All three major international vascular surgical societies—the European Society for Vascular Surgery (ESVS), the Society for Vascular Surgery (SVS), and the World Federation of Vascular Societies (WFVS)—combined efforts, along with nearly 60 experts all over the world, to put together the exhaustive compendium over the last 4 years with the intent to globally improve care for CLTI. 

Chronic limb-threatening ischemia (CLTI) is a new term coined in the guidelines in place of critical limb ischemia, which is defined as a severe obstruction of the arteries that markely reduces blood flow to the hands, feet, and legs, and has progressed to the point of severe pain, skin ulcers, and/or sores. It is the final stage of peripheral artery disease (PAD), which results from a progressive thickening of an artery’s lining that raises the risk of heart attack, stroke and death. According to the report, “CLTI is a highly morbid disease, incurring significant mortality, limb loss, pain, and diminished health-related quality of life among those afflicted.” Treatment is required immediately in order to re-establish blood flow to the affected areas, and above all to preserve the limb.

The guidelines represent a synthesis of the treatments used to treat this debilitating condition, and emphasize the importance of a structured approach to decision-making on revascularization, taking into account Patient risk, Limb severity and ANatomic complexity (PLAN) in that order. A new anatomic classification system, the Global Anatomic Staging System (GLASS), is proposed to replace prior schemes that were primarily lesion-based, rather than limb-based.

According to Dr. Conte in his statement to the SVS, “By improving the staging of CLTI, we believe that optimal care pathways can be defined and based on more accurate clinical and epidemiologic evidence going forward…with the continuous evolution of vascular technology, we must remain focused on the primary goals of treatment, in contradistinction to a lesion-centric emphasis on technical success.”

Overall recommendations from the guidelines emphasize the need for comprehensive assessments for CLTI, optimal medical therapy, and prompt revascularization for patients with advanced CLTI, in addition to utilizing an individualized approach for each patient.

Read the SVS press release

Read the full text of the GVG on the JVS website