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CLINICAL STATEMENTS AND GUIDELINES June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1368 predict, and compare clinical presentation and outcomes. Observational and registry data exist to validate the use of WIfI and GLASS classification models26–30 and, to this end, a broader application of these tools is suggested. Moreover, the practice of maintaining and reviewing these data may have an impact in identifying opportunities to improve quality and outcomes (eg, limb salvage, mortality) at the level of the individual clinician, multispecialty care team, and hospital system. The VQI is a multicentered patient registry that collects clinical, procedural, and outcome data from participating centers and includes patients treated for CLTI.31 Although data on center-specific outcomes relative to other participating centers regionally and nationally are provided to the individual participating programs for purposes of quality improvement, the center-specific data from the VQI are not publicly reported. Other quality improvement registries that include patients with CLTI (with emphasis on endovascular procedures) are the NCDR PVI Registry and the Society of Interventional Radiology VIRTEX data registry.31,32 Although none of these registries report data publicly, they do allow participating centers to benchmark procedural outcomes compared with other centers. Various examples of public reporting of procedural and chronic cardiovascular condition care outcomes are available, including the Society of Thoracic Surgery reporting of coronary artery bypass and valve surgery and the NCDR reporting of outcomes after percutaneous coronary intervention and MI.33,34 Much has been written about potential consequences of a poorly designed reporting structure that may perversely impact patient care.35 Decades of experience across these domains may be helpful in the design of a future public reporting structure for CLTI outcomes, including amputation. 11 ACUTE LIMB ISCHEMIA ALI is one of the most treatable and potentially devastating presentations of PAD. Timely recognition of acute arterial occlusion as the cause of an ischemic, cold, painful, and/or numb limb is crucial to successful treatment. The writing committee has used a standard definition of ALI in which symptom duration is <2 weeks1,2 (Figure 8). Category I ALI refers to a viable limb that is not immediately threatened. Category II refers to the threatened but salvageable limb. The category IIa limb is marginally threatened and salvageable, if promptly treated. The category IIb limb is immediately threatened and requires immediate revascularization if salvage is to be accomplished. The category III limb is irreversibly damaged, in which case resultant major tissue loss or permanent nerve damage is inevitable.2 The category III limb is nonsalvageable. 11.1 Initial Clinical Evaluation and Diagnostic Approach to ALI Recommendations for the Initial Clinical Evaluation and Diagnostic Approach to ALI Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 C-EO 1 Patients with ALI should be evaluated on an emergency basis by a clinician with sufficient experience to assess limb viability and implement appropriate therapy. 1 C-LD 2 In patients with suspected ALI, the initial clinical evaluation should rapidly assess limb viability and potential for salvage and can be achieved without noninvasive imaging (ie, duplex ultrasound, CTA, or MRA).1–6 2b C-EO 3 In patients with ALI who have a complicated history of revascularization procedures, it may be reasonable to obtain noninvasive imaging (ie, duplex ultrasound, CTA, or MRA) before deciding to proceed with revascularization. Synopsis ALI is a vascular emergency that requires rapid recognition, assessment of limb viability, and timely implementation of therapy to maximize the possibility of limb salvage. If local expertise is unavailable for rapid assessment and potential revascularization, patient transfer to a facility with such resources should be considered. Initial evaluation of ALI includes targeted history and physical examination, including use of a continuous wave Doppler device at the bedside to assess arterial and venous signals in the limb (Figure 8). In most cases, treatment for ALI is implemented without the need for additional noninvasive imaging studies (ie, duplex ultrasound, CTA, MRA). Recommendation-Specific Supportive Text 1 Patients with ALI should be evaluated on an emer- gency basis by a clinician with sufficient experience to assess limb viability and implement appropriate therapy. If such expertise is locally unavailable, transfer of the patient with ALI to a facility with such resources should be strongly considered. The more advanced the degree of ischemia, the more rapidly the communication (including communication about potential patient transfer) needs to occur. 2. ALI is a medical emergency that must be recog- nized rapidly. The time constraint is attributable to the period that skeletal muscle will tolerate ischemia—about 4 to 6 hours.5 A focused history and physical examination with rapid assessment of limb viability and ability to restore arterial blood flow Downloaded from http://ahajournals.org by on October 7, 2026