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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Patients at high risk of developing complications of venous disease may be identified by an accurate non-invasive evaluation of reflux patterns.

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Carotid aneurysms are rare, and pregnancy-related carotid aneurysms are rarer still. We report the case of an extracranial carotid aneurysm related to pregnancy. It was noted in the 20th week of gestation, and was uncomplicated. Surgery was successfully performed urgently to preempt embolism or rupture. The patient had a full-term normal delivery. The graft is patent, and the patient has no symptoms at 28-month follow-up. To the best of our knowledge, this case represents the first successful repair of an extracranial carotid aneurysm during pregnancy.

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All four patients who had arterial ligation performed proximal to the inguinal ligament were critically ischemic after ligation while when the level of ligation was below the inguinal ligament 14 out of 16 patients were compensated (significant).Pedal doppler flow signal was detected in ten patients only intraoperatively. However, four more patients regained Doppler signal in the ward few hours after the operation. All 14 patients with Doppler signal were compensated and required no further revascularization for limb salvage till discharge from hospital.In compensated patients the mean pre-operative ABI was 0.88 and the mean post-operative ABI was 0.49 with an average ABI drop of 0.39. However, in patients who required revascularization or amputation, the mean preoperative ABI was 0.83 and the mean post-operative ABI was 0.00 with an average ABI drop of 0.83 Conclusion -In drug addicts with infected femoral pseudoaneurysms, arterial ligation with local debridement without revascularization salvaged 70% of limbs in our study. The detection of pedal Doppler flow after ligation can stratify patients in whom revascularization might not be required for limb salvage. Additionally all efforts should be made to ligate the femoral artery below the inguinal ligament to preserve important juxta-inguinal collateral branches that can have great impact on limb outcome after ligation.