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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1367

appropriate, and using a team-based approach, minor amputation below the malleolus may be possible for patients in whom continued ambulation is anticipated. Regarding a perceived biomechanical advantage of different foot amputations (eg, transmetatarsal amputation, Chopart, Lisfranc), conflicting evidence exists regarding the comparative benefit of foot level amputation relative to a functional below-the-knee amputation. Patient education, appropriate extremity pressure offloading with prescription shoes, and foot surveillance clinical examinations are essential to reducing wound recurrence, especially in patients with diabetes and neuropathy who have had CLTI. Wound complications, including at the stump site, and hospital readmission rates among patients with CLTI undergoing major limb amputation are high and reflect the burden of advanced CVD, diabetes, residual infection, ongoing smoking, and other medical comorbidities in this patient population.13–15 Implementation of a plan for management of diabetes and medical comorbidities by the multispecialty care team at the time of amputation is important. 2.	 Clinical situations can occur in which life over limb is the prevailing factor and emergency primary amputation is indicated. This includes the patient with advanced soft-tissue infection where emergency amputation for sepsis control is the only viable option to avoid patient death or in the setting of severe metabolic derangements attributable to extensive tissue necrosis. 3.	 The use of published classification tools (WIfI,

GLASS)16,17 may facilitate the objective assessment and documentation of the no-option patient (Table 18). A nonrandomized series reported healing rates approaching 50% in a cohort with CLTI with a nonrevascularization strategy focused on local wound management.18,19 With or without an associated wound, the patient’s subjective experience of pain is an important individual variable and must be appropriately assessed and managed. When revascularization is not an option, local wound management measures fail, or pain is prohibitive, primary amputation may be the only option to relieve the pain. In addition, a subgroup of patients presenting with CLTI will have severe comorbid conditions that contribute to the decisional matrix that revascularization may not be physiologically tolerated and render primary amputation as the most appropriate clinical option. Other clinical situations may exist in which primary amputation for CLTI is considered, including the patient with such extensive tissue destruction that surgical resection would result in a nonfunctional extremity, the patient who is nonambulatory or entirely bedbound at baseline because of chronic comorbidity (eg, stroke, persistent vegetative state), or the patient with a short life expectancy (eg, advanced age, untreatable cancer). Primary amputation should only be considered after thorough review by an experienced revascularization specialist in consultation with the multispecialty care team (Table 15) and in discussion with the patient and family members incorporating the patient’s input and goals of care. 4.	 Patients with CLTI who have undergone a minor

(inframalleolar) amputation are at risk for woundrelated complications, including infection, as well as future major amputation.13,20 For such patients, a customized program of longitudinal care is essential, including local wound care and appropriate foot pressure offloading to facilitate wound healing. Evidence for the use of adjuncts, such as tendon Achilles lengthening and tendon balancing, are supported largely by observational studies.21–25 After the initial healing, wound recurrence rates are high in neuroischemic patients, and diligent long-term patient surveillance and meticulous foot care, including periodic assessment of biomechanics and need for therapeutic footwear, is essential to prevent these events (see Section 5.8, “Preventive Foot Care for PAD,” and Section 10.3.3.1, “Pressure Offloading for CLTI”). One or more members of the multispecialty care team (Table 15) who has expertise in this domain should be designated with this role and should be engaged for longitudinal follow-up care of the patient after minor amputation for CLTI. 5.	 Application of objective classification tools (eg,

WIfI, GLASS) in program evaluation and hospitallevel reporting of outcomes in the CLTI patient cohort enhances the ability to objectively describe,

Table 19.  Major Factors Influencing QOL Among Amputees Patient factors Higher QOL Walking with prosthesis Above knee (versus below knee) amputation Female sex (especially if age <60 y) Living at home Lower QOL Age >65 y Presence of diabetes Isolation (being homebound) Professional-controlled factors Timing of amputation Informed decision-making Postamputation support Data derived from Davie-Smith et al10 and Suckow et al.9 Reprinted with permission from Creager et al.8 Copyright 2021 American Heart Association, Inc.

QOL indicates quality of life.

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