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.

No abstract

To attain better ulcer healing rates combined with higher limb salvage, direct revascularization of the ischemic angiosome should be considered whenever possible. Revascularization should not be denied to patients with indirect perfusion of the ischemic angiosome as acceptable rates of limb salvage are obtained.

Use of bone marrow-derived progenitor cell transplantation into ischemic limbs is a relatively safe procedure with no demonstrable side effects at 6 months. These study data support conducting controlled and multicenter trials to evaluate the efficacy of this therapy in preventing amputation in selected patients with Buerger's disease who have critical limb ischemia.

No abstract

A 21-year man presented with nonspecific mid-abdominal pain, with no other symptoms. Abdominal ultrasound imaging revealed an inferior vena cava (IVC) aneurysm, and the patient was referred for further management.Physical examination was unremarkable except for mild tenderness in the right lower quadrant. There were no palpable masses or abdominal bruits. The results of laboratory analysis were normal. A computed tomography angiogram (CTA) revealed a 6.65-cm ϫ 5.01-cm saccular aneurysm arising from the right lateral aspect of the IVC at the confluence of iliac veins (A). There was no thrombus in the aneurysm, and there were no other findings on the CTA (Cover image).Considering his young age, we decided to proceed with surgical repair. The infrarenal IVC and both iliac veins were exposed through a midline laparotomy and right retroperitoneal approach. The right common iliac artery and ureter were adherent to the aneurysm, but could be easily separated (B). The aneurysm was completely resected, and lateral venorrhaphy with continuous 6.0 Prolene (Ethicon, Somerville, NJ) effectively closed the "mouth" of the aneurysm without compromising the caval lumen (C). The patient's recovery was uneventful, and he was discharged on the sixth postoperative day with oral anticoagulation.

Background: Acute limb ischemia (ALI) is any sudden decrease in limb perfusion causing a potential threat to limb viability. It is generally accepted that in a patient without underlying arterial disease who develops an acute arterial blockage has approximately six hours for revascularisation before irreversible damage occurs. This study endeavoured to analyse and evaluate the causes and clinical outcome of acute lower limb ischemia.Methods: 80 successive patients visiting Jain Institute of Vascular Sciences, Bangalore who were diagnosed to have ALI were included in this prospective study. Thromboembolectomy was performed in 48% of patients, 9% of patients were managed with anticoagulation alone, 8% of patients were treated by catheter directed thrombolysis and primary amputation was inevitable in 16 patients of class III ischemia.Results: All the five patients who presented within the golden six hours survived and their limbs could be salvaged without any morbidity. Even in patients with delayed presentation but viable limb (47 patients) functional limb salvage was possible in 39 patients (82.9%). Overall there was 72.73% limb salvage and 27.27% patients underwent amputation. There was a mortality rate of 13.16% in the study.Conclusions: Overall there was 72.73% limb salvage and 27.27% patients underwent amputation. Revascularization within six hours is ideal (only 6.25% of patients in our study); however, in delayed presentation (93.75%), physiological state of the limb, rather than elapsed time from onset of occlusion will determine the operability. Late revascularization may thus be indicated and is often successful if limb still exhibits signs of viability.

No abstract