慢性威胁肢体缺血(CLTI)与死亡率相关,截肢,生活质量受损。这些全球血管指南(GVG)的重点是定义,评估,和CLTI的管理,以改善循证护理和突出关键研究需求为目标。术语CLTI优于严重肢体缺血,因为后者意味着受损灌注的阈值,而不是连续体。CLTI是一种临床综合征,由外周动脉疾病(PAD)的存在与静息疼痛,坏疽,或下肢溃疡>2周持续时间。静脉,创伤性,栓塞,非动脉粥样硬化病因被排除.所有疑似CLTI的患者应紧急转诊至血管专科医生。准确分期肢体威胁的严重程度是至关重要的,血管外科学会威胁肢体分类系统,基于伤口的分级,缺血,足部感染(WIfI)得到认可。客观的血液动力学测试,包括脚趾压力作为首选措施,需要评估CLTI。循证血运重建(EBR)取决于三个独立的轴:患者风险,肢体严重程度,和解剖复杂性(计划)。平均风险和高风险患者由估计的手术死亡率和2年全因死亡率来定义。GVG提出了一种新的全球解剖分期系统(GLASS),这包括定义一个优选的目标动脉路径(TAP),然后估计基于肢体的通畅性(LBP),导致干预的三个阶段复杂。最佳血运重建策略也受到开放旁路手术自体静脉的可用性的影响。EBR的建议基于最佳可用数据,正在进行的审判中的1级证据。静脉旁路术可能是患有晚期肢体威胁和高度复杂性疾病的平均风险患者的首选。而那些解剖结构不太复杂的人,中度严重肢体威胁,或高患者风险可能有利于血管内介入治疗。所有CLTI患者均应接受最佳药物治疗,包括使用抗血栓药物。降脂,抗高血压药,和血糖控制药物,以及戒烟咨询,饮食,锻炼,和预防性足部护理。在EBR之后,建议进行长期肢体监测.非血运重建治疗的有效性(例如,脊髓刺激,气动压缩,前列腺素,和高压氧)尚未建立。再生医学方法(例如,cell,CLTI的基因治疗)应仅限于严格进行的随机临床试验。GVG促进CLTI临床试验的研究设计和终点的标准化。强调了多学科团队和卓越中心对预防截肢的重要性,这是卫生系统的一项关键举措。
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular
Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.