Management of chronic limb ischemia in lower extremity peripheral arterial disease: Difference between revisions
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==Recommendations for Management of CLI (critical limb ischemia) in the Patient With PAD== | ==Recommendations for Management of CLI (critical limb ischemia) in the Patient With PAD== | ||
===Recommendation for Revascularization for CLI=== | ===Recommendation for Revascularization for CLI:=== | ||
{|class="wikitable" | {|class="wikitable" | ||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''In patients with CLI, revascularization should be performed when possible to minimize tissue loss ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''In patients with CLI, revascularization should be performed when possible to minimize tissue loss.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''An evaluation for revascularization options should be performed by an interdisciplinary care team before amputation in the patient with CLI ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''An evaluation for revascularization options should be performed by an interdisciplinary care team before amputation in the patient with CLI.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
====Recommendations for Endovascular Revascularization for CLI==== | ====Recommendations for Endovascular Revascularization for CLI:==== | ||
{|class="wikitable" | {|class="wikitable" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' A staged approach to endovascular procedures is reasonable in patients with ischemic rest pain ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' A staged approach to endovascular procedures is reasonable in patients with ischemic rest pain. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Evaluation of lesion characteristics can be useful in selecting the endovascular approach for CLI''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Evaluation of lesion characteristics can be useful in selecting the endovascular approach for CLI.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Use of angiosome-directed endovascular therapy may be reasonable for patients with CLI and nonhealing wounds or gangrene ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Use of angiosome-directed endovascular therapy may be reasonable for patients with CLI and nonhealing wounds or gangrene. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
====Recommendations for Surgical Revascularization for CLI==== | ====Recommendations for Surgical Revascularization for CLI:==== | ||
{|class="wikitable" | {|class="wikitable" | ||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''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.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Surgical procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Surgical procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' A staged approach to surgical procedures is reasonable in patients with ischemic rest pain ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' A staged approach to surgical procedures is reasonable in patients with ischemic rest pain. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
===Recommendation for Wound Healing Therapy=== | ===Recommendation for Wound Healing Therapy:=== | ||
{|class="wikitable" | {|class="wikitable" | ||
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| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit) | | colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit) | ||
|- | |- | ||
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Prostanoids are not indicated in patients with CLI ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki> | | bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Prostanoids are not indicated in patients with CLI. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' patients with CLI, the effectiveness of hyperbaric oxygen therapy for wound healing is unknown''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' patients with CLI, the effectiveness of hyperbaric oxygen therapy for wound healing is unknown. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} |
Revision as of 19:51, 22 November 2016
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
- ↑ 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.