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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1359 Recommendation-Specific Supportive Text 1 The components of multispecialty care teams for CLTI include expertise in revascularization, pressure offloading, treatment of infection, and wound care, among other areas of expertise (Table 15). The management of patients with CLTI and nonhealing wounds should include coordinated efforts for both revascularization and wound healing because the risk of limbthreatening infections remains until complete wound healing is achieved. The structure and activities of such multidisciplinary care teams may vary according to several factors, including the local availability of resources. Previous groups have described various combinations of activities of this team, which are in addition to revascularization, and include functions such as wound care, infection management, rehabilitation, orthotics, and prosthetics.1–3 A multisocietal document on competencies for endovascular specialists on the multispecialty care team has been published.4 Multispecialty care teams should also include expertise in the medical management of diabetes, which is particularly important in the context of CLTI. Coordination of care and communication among team members is important, versus ad hoc or unstructured referrals among various specialty clinicians not involved in interdisciplinary care. Patients with CLTI must be evaluated by a multispecialty care team before major amputation, except in instances of life-threatening sepsis. The objective of this strategy is to evaluate all revascularization and therapeutic options with the goal of preserving a functional limb. 10.2 Revascularization for CLTI Recommendations for Revascularization for CLTI Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations Revascularization Goals for CLTI 1 B-R 1 In patients with CLTI, surgical, endovascular, or hybrid revascularization techniques are recommended, when feasible, to minimize tissue loss, heal wounds, relieve pain, and preserve a functional limb.1–14 1 C-EO 2 In patients with CLTI, an evaluation for revasculariza- tion options by a multispecialty care team is recommended before amputation (Table 15). Revascularization Strategy for CLTI 1 A 3 In patients undergoing surgical revascularization for CLTI, bypass to the popliteal or infrapopliteal arteries (ie, tibial, pedal) should be constructed with autogenous vein if available.14–20 1 B-R 4. In patients with CLTI due to infrainguinal disease, anatomy, available conduit, patient comorbidities, and patient preferences should be considered in selecting the optimal first revascularization strategy (surgical bypass or endovascular revascularization) (Table 16).3,13 1 B-R 5 In patients with CLTI who are candidates for surgical bypass and endovascular revascularization, ultrasound mapping of the great saphenous vein is recommended.3,13 2a B-NR 6 In patients with CLTI for whom a surgical approach is selected and a suitable autogenous vein is unavailable, alternative conduits such as prosthetic or cadaveric grafts can be effective for bypass to the popliteal and tibial arteries.21–26 2a B-NR 7 In patients with CLTI and nonhealing wounds or gangrene, revascularization in a manner that achieves in-line blood flow or maximizes perfusion to the wound bed can be beneficial.27–33 2a C-LD 8 In patients with CLTI with ischemic rest pain (ie, with- out nonhealing wounds or gangrene) attributable to multilevel arterial disease, a revascularization strategy addressing inflow disease first is reasonable.34,35 Synopsis The central component of the care of patients with CLTI is revascularization to improve blood flow to the limb, with the goals of preventing amputation and minimizing tissue loss to preserve a functional limb, heal wounds, Table 15. Multispecialty Care Team for PAD A team of professionals representing different specialties and disciplines to assist in the evaluation and management of the patient with PAD. For the care of patients who also have CLTI, the team should include individuals who are skilled in endovascular revascularization, surgical revascularization, wound-healing therapies and foot surgery, and medical evaluation and care. Interdisciplinary care team members may include: Vascular medical and surgical specialists (ie, vascular medicine, vascular surgery, vascular interventional radiology, interventional cardiology) Advance practice provider–nurse practitioners/physician assistants Nurses Podiatrists, orthopedic surgeons, or both Wound care specialists Endocrinologists Internal medicine specialists Infectious disease specialists Diagnostic radiologists and other vascular imaging specialists Pharmacists Physical medicine and rehabilitation clinicians Social workers Clinical exercise physiologists Physical and occupational therapists Nutritionists and dieticians Patients and family members (collaborate with multispecialty care team) Modified with permission from Gerhard-Herman et al.5 Copyright 2017 American Heart Association, Inc., and American College of Cardiology Foundation. CLTI indicates chronic limb-threatening ischemia; and PAD, peripheral artery disease. 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