Management of chronic limb ischemia in lower extremity peripheral arterial disease

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AHA/ACC Guidelines on Management of Lower Extremity PAD

Guidelines for Clinical Assessment of Lower Extremity PAD

Guidelines for Diagnostic Testing for suspected PAD

Guidelines for Screening for Atherosclerotic Disease in Other Vascular Beds in patients with Lower Extremity PAD

Guidelines for Medical Therapy for Lower Extremity PAD

Guidelines for Structured Exercise Therapy for Lower Extremity PAD

Guidelines for Minimizing Tissue Loss in Lower Extremity PAD

Guidelines for Revascularization of Claudication in Lower Extremity PAD

Guidelines for Management of CLI in Lower Extremity PAD

Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD

Guidelines for Longitudinal Follow-up for Lower Extremity PAD

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease[1]

Recommendations for Management of CLI (critical limb ischemia) in the Patient With PAD

Recommendation for Revascularization for CLI:

Class I
"1.In patients with CLI, revascularization should be performed when possible to minimize tissue loss.(Level of Evidence: B-NR)"
"2.An evaluation for revascularization options should be performed by an interdisciplinary care team before amputation in the patient with CLI.(Level of Evidence: C-EO)"

Recommendations for Endovascular Revascularization for CLI:

Class I
"1.Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene.(Level of Evidence: B-R)"
Class IIa
"1. A staged approach to endovascular procedures is reasonable in patients with ischemic rest pain. (Level of Evidence: C-LD)"
"2. Evaluation of lesion characteristics can be useful in selecting the endovascular approach for CLI.(Level of Evidence: B-R)"
Class IIb
"1.Use of angiosome-directed endovascular therapy may be reasonable for patients with CLI and nonhealing wounds or gangrene. (Level of Evidence: B-NR)"

Recommendations for Surgical Revascularization for CLI:

Class I
"1. When surgery is performed for CLI, bypass to the popliteal or infrapopliteal arteries (i.e., tibial, pedal) should be constructed with suitable autogenous vein.(Level of Evidence: A)"
"2. Surgical procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene. (Level of Evidence: C-LD)"
Class IIa
"1. In patients with CLI for whom endovascular revascularization has failed and a suitable autogenous vein is not available, prosthetic material can be effective for bypass to the below-knee popliteal and tibial arteries. (Level of Evidence: B-NR)"
"2. A staged approach to surgical procedures is reasonable in patients with ischemic rest pain. (Level of Evidence: C-LD)"

Recommendation for Wound Healing Therapy:

Class I
"1. An interdisciplinary care team should evaluate and provide comprehensive care for patients with CLI and tissue loss to achieve complete wound healing and a functional foot(Level of Evidence: B-NR)"
"2. In patients with CLI, wound care after revascularization should be performed with the goal of complete wound healing(Level of Evidence: C-LD)"
Class III (No Benefit)
"1. Prostanoids are not indicated in patients with CLI. (Level of Evidence: B-R)"
Class IIb
"1. In patients with CLI, intermittent pneumatic compression (arterial pump) devices may be considered to augment wound healing and/or ameliorate severe ischemic rest pain. (Level of Evidence: B-NR)"
"2. patients with CLI, the effectiveness of hyperbaric oxygen therapy for wound healing is unknown. (Level of Evidence: C-LD)"


References

  1. Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE; et al. (2016). "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000471. PMID 27840333.