Global vascular guidelines on the management of chronic limb-threatening ischemia.
Global vascular guidelines on the management of chronic limb-threatening ischemia.
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DOI：
10.1016/j.jvs.2019.02.016
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发表时间：
2019-06
影响因子：
4.3
通讯作者：
GVG Writing Group
中科院分区：
文献类型：
--
作者：
Conte MS;Bradbury AW;Kolh P;White JV;Dick F;Fitridge R;Mills JL;Ricco JB;Suresh KR;Murad MH;GVG Writing Group
慢性威胁肢体缺血（CLTI）与死亡率、截肢和生活质量受损相关。这些全球血管指南（GVG）侧重于CLTI的定义、评价和管理，旨在改善循证护理并强调关键的研究需求。术语CLTI优于严重肢体缺血，因为后者意味着灌注受损的阈值而不是连续性。CLTI是一种临床综合征，定义为外周动脉疾病（PAD）伴静息痛、坏疽或下肢溃疡持续时间>2周。排除静脉、创伤、栓塞和非动脉粥样硬化病因。所有疑似CLTI的患者应紧急转诊至血管专家。对肢体威胁的严重程度进行准确分期是至关重要的，血管外科学会基于伤口、缺血和足部感染（WIfI）分级的肢体威胁分类系统得到了认可。客观的血流动力学测试，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，肢体严重度和解剖复杂性（EBR）。通过估计的手术和2年全因死亡率定义平均风险和高风险患者。GVG提出了一种新的全球解剖分期系统（GLASS），该系统涉及定义首选靶动脉路径（TAP），然后估计基于肢体的通畅性（LBP），导致介入的三个复杂阶段。最佳的血运重建策略也受到开放式搭桥手术中自体静脉可用性的影响。EBR的建议基于最佳可用数据，等待来自正在进行的试验的1级证据。对于具有晚期肢体威胁和高复杂性疾病的平均风险患者，静脉旁路可能是首选，而对于解剖结构不太复杂、中度肢体威胁或高患者风险的患者，血管内介入可能更受欢迎。所有CLTI患者都应接受最佳药物治疗，包括使用抗血栓、降脂、降压和血糖控制药物，以及戒烟、饮食、运动和预防性足部护理方面的咨询。在EBR之后，建议进行长期肢体监测。非血运重建疗法（如脊髓刺激、气动压迫、前列腺素类和高压氧）的有效性尚未确定。CLTI的再生医学方法（例如，细胞，基因疗法）应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标准化。强调了多学科团队和卓越中心对截肢预防的重要性，将其作为一项关键的卫生系统倡议。
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.
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影响因子：
4.3
作者：
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通讯作者：
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作者：
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通讯作者：
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