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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1360

and relieve PAD-associated pain (Figures 6 and 7). Revascularization for CLTI may include endovascular and surgical procedures as well as hybrid procedures that combine both approaches, either concomitantly or in a staged fashion. Surgical approaches, including bypass and endarterectomy, can be used for revascularization of CLTI. Technical aspects of surgery for CLTI, including availability of high-quality autogenous (eg, saphenous) vein conduit, are important determinants of success and should be carefully considered by the multispecialty care team. Numerous endovascular techniques are available to facilitate procedural success, and lesion characteristics are used in selecting the specific endovascular approach to revascularization for CLTI. The BEST-CLI (Best Endovascular versus Best Surgical Therapy in Patients with CLI) and BASIL-2 (Bypass versus Angioplasty for Severe Ischaemia of the Leg) trials have further informed revascularization strategy in patients with CLTI.3,13 Factors that may influence revascularization strategy for CLTI are shown in Table 16. Recommendation-Specific Supportive Text Revascularization Goals for CLTI

1 Patients with CLTI are at high risk of major ampu-

tation as well as MACE, including death. In a systematic review of 13 studies of patients with CLTI who did not receive revascularization and that included patients enrolled in medical and angiogenic therapy trials, a 22% all-cause mortality rate and a 22% rate of major amputation at a median follow-up of 12 months were observed.1 Thus, all patients with CLTI should undergo assessment for revascularization (Figure 7). Revascularization can be accomplished by endovascular, surgical, and hybrid approaches, and data from RCTs and observational evidence inform revascularization strategy in CLTI.36 Both endovascular and surgical revascularization have been demonstrated to be effective treatments for preventing amputation in CLTI.2,3,13,14,36–40 Hybrid revascularization techniques can also be used for revascularization of PAD, especially for patient anatomy including aortoiliac disease, and the use of hybrid revascularization procedures is supported by observational studies.5,6,9–11,41–45 In the aortoiliac segment, less invasive hybrid procedures have similar primary patency and limb salvage rates when compared with open surgical reconstruction,4,5,45 especially when using covered stent grafts.4,6,7,45 Similarly, hybrid infrainguinal interventions have similar patency and limb salvage rates to open bypass in selected patients.8–12

2 In nonemergency circumstances (ie, patients who

are not septic from lower extremity ischemia and infection), evaluation by a multispecialty care team, when available, before amputation (Table 15) is recommended to potentially identify revascularization options and other ways to preserve a functional limb. Such an evaluation generally includes imaging for assessment of revascularization options (eg, duplex ultrasound, CTA, MRA, or catheter-based angiogram), assessment of the presence and degree of infection, bony abnormalities, if any, and the overall functional status of the patient. The objective of this strategy is to minimize tissue loss and preserve a functional limb with revascularization. Revascularization, with its associated procedural risk, is not warranted in the setting of a nonviable limb. For patients in this setting, palliative management of the limb, including continued wound care, pain control, and amputation

Table 16.  Factors That May Influence Revascularization Strategy for CLTI Factors That May Influence Optimal Revascularization Modality Clinical Examples (Other Factors Being Equal) Anatomy Strategy for current revascularization considers history of failed previous revascularization procedures (surgical, endovascular, or both)

Anatomic characteristics that may favor surgical revascularization include: lesions involving both the common femoral artery and origin of the profunda femoris artery multilevel chronic total occlusions lesions in which endovascular treatment would adversely impact future surgical bypass options lesions that are long segment, involving the below-knee popliteal and infrapopliteal arteries

Available conduit Absence of suitable autogenous vein (eg, due to previous harvest for coronary artery bypass surgery) may favor endovascular revascularization. Patient comorbidities High estimated perioperative risk (eg, coronary ischemia, cardiomyopathy and heart failure, severe lung disease, CKD, and frailty) may favor endovascular revascularization. Patient preferences Patient preference for 1 revascularization modality (surgical or endovascular) over the other, after participating in shared decision-making. Modified with permission from Gerhard-Herman et al.5 Copyright 2017 American Heart Association, Inc., and American College of Cardiology Foundation. CKD indicates chronic kidney disease; and CLTI, chronic limb-threatening ischemia.

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