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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1362

cephalic and basilic) veins. If formal vascular laboratory-based duplex ultrasound is unavailable, saphenous vein assessment may be performed at the bedside using point-of-care ultrasound, although mapping performed in a vascular laboratory setting by certified personnel is preferred. 6.	 Although autogenous veins are the preferred con-

duit for surgical revascularization, prosthetic conduit is a secondary option for patients with CLTI without suitable saphenous veins who require surgical revascularization. Studies have shown that patients can be treated successfully with autogenous vein bypass graft22,23 or prosthetic bypass graft21,24 even after previous endovascular intervention. Studies have explored the efficacy of use of a prosthetic bypass with distal autogenous vein cuff in patients with CLTI. These circular vein patches, intended to limit narrowing where the prosthetic graft meets the target artery, have shown mixed results.52,56,57 Data supporting the use of cadaveric vein graft conduit for patients with CLTI are limited; however, this also remains an option for patients for whom a surgical revascularization strategy is undertaken and autogenous vein conduit is unavailable.25,26

7 The goal of revascularization for CLTI is to maxi-

mize blood flow to the foot. Historically, operators have tried to provide in-line blood flow to a named infrapopliteal artery to the foot.27,28,30,58–60 However, in some instances, no option is available to provide in-line blood flow to a named infrapopliteal artery. A more recent paradigm for revascularization for PAD focuses on maximizing perfusion to the wound bed. For patients with wounds due to CLTI, the goal is to provide direct pulsatile flow to the wound bed, or “angiosome.” This can be accomplished through direct revascularization or indirect revascularization via collaterals but is less certain after indirect revascularization without visible collaterals.61,62 Data from meta-analyses of patients undergoing endovascular therapy for CLTI suggest that amputation rates are lowest for direct revascularization, intermediate for indirect revascularization via collaterals, and highest for indirect revascularization; similarly, wound healing associated with direct revascularization and indirect revascularization via collaterals appears similar but is less favorable after indirect revascularization.29–31 In meta-analyses of patients who underwent either surgical bypass or endovascular therapy, superior wound-healing rate, shorter time to wound healing, and superior limb salvage have been observed with direct revascularization compared with indirect revascularization, but these associations are only apparent for patients undergoing endovascular revascularization.29–33

8 For patients with multilevel disease and isch-

emic rest pain (ie, no wounds or tissue loss), inflow lesions are generally addressed first.34,35 Depending on procedural characteristics, including contrast volume used, radiation exposure, and procedure time, outflow lesions can be addressed in the same procedure setting or at a later time if symptoms persist. This strategy for ischemic rest pain is distinct from the strategy for the patient with CLTI and tissue loss (ie, nonhealing wound or gangrene). In cases of CLTI with tissue loss, patients generally require revascularization to the greatest extent possible, often treating both inflow and outflow lesions at the same setting, to optimize wound healing.

10.3 Minimizing Tissue Loss for CLTI

10.3.1 Pressure Offloading for CLTI

Recommendations for Pressure Offloading for CLTI Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 A 1 Patients with CLTI and diabetic foot ulcers should

receive pressure offloading, when possible, to promote tissue growth and wound healing.1–9

1 B-R 2 Patients with PAD and previous diabetic foot ulcers

should be referred for customized footwear that accommodates, protects, and fits the shape of their feet.10–12

2b C-EO 3 Patients with CLTI and foot ulcers who do not have

diabetes may be considered for pressure offloading to promote tissue growth and wound healing.

Synopsis Pressure offloading is a component of management of the patient with CLTI (Figure 7). Excessive or persistent pressure combined with a loss of protective sensation of the plantar aspect of the foot leads to tissue loss and diabetic foot ulcers. Shear, compressive, frictional, and tensile forces are the main causes of diabetic foot ulcers and may be a manifestation of CLTI in patients with concomitant diabetes and PAD. Because of the complexity of the human foot during weight bearing, consideration of anatomy, mechanics, and sensation is required to evaluate function and determine appropriate pressure offloading therapy, especially in patients with CLTI. Podiatrists or other foot-trained professionals (eg, orthopedic surgeons, orthotists and prosthetists, specialist nurses) are best suited to evaluate these patients for pressure offloading and are important members of the multispecialty care team. When a podiatric service is unavailable locally, pressure offloading and wound care strategies can be coordinated by the available multispecialty care team. Most published literature supports the use of pressure offloading strategies in the context of diabetic foot ulcers, but these may also be applied to patients with CLTI and foot wounds without diabetes.

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