Berchiolli Raffaella, Bertagna Giulia, Adami Daniele, Canovaro Francesco, Torri Lorenzo, Troisi Nicola
Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy.
J Clin Med. 2023 Apr 4;12(7):2682. doi: 10.3390/jcm12072682.
Patients presenting with critical limb-threatening ischemia (CLTI) have been increasing in number over the years. They represent a high-risk population, especially in terms of major amputation and mortality. Despite multiple guidelines concerning their management, it continues to be challenging. Decision-making between surgical and endovascular procedures should be well established, but there is still a lack of consensus concerning the best treatment strategy. The aim of this manuscript is to offer an overview of the contemporary management of CLTI patients, with a focus on the concept that evidence-based revascularization (EBR) could help surgeons to provide more appropriate treatment, avoiding improper procedures, as well as too-high-risk ones.
We performed a search on MEDLINE, Embase, and Scopus from 1 January 1995 to 31 December 2022 and reviewed Global and ESVS Guidelines. A total of 150 articles were screened, but only those of high quality were considered and included in a narrative synthesis.
Global Vascular Guidelines have improved and standardized the way to classify and manage CLTI patients with evidence-based revascularization (EBR). Nevertheless, considering that not all patients are suitable for revascularization, a key strategy could be to stratify unfit patients by considering both clinical and non-clinical risk factors, in accordance with the concept of individual residual risk for every patient. The recent BEST-CLI trial established the superiority of autologous vein bypass graft over endovascular therapy for the revascularization of CLTI patients. However, no-option CLTI patients still represent a critical issue.
The surgeon's experience and skillfulness are the cornerstones of treatment and of a multidisciplinary approach. The recent BEST-CLI trial established that open surgical peripheral vascular surgery could guarantee better outcomes than the less invasive endovascular approach.
近年来，患有严重肢体缺血（CLTI）的患者数量一直在增加。他们是高危人群，尤其是在大截肢和死亡率方面。尽管有多项关于其治疗的指南，但治疗仍具有挑战性。手术和血管内介入治疗之间的决策应明确，但对于最佳治疗策略仍缺乏共识。本文的目的是概述CLTI患者的当代治疗方法，重点关注基于证据的血管重建（EBR）这一概念，它可以帮助外科医生提供更合适的治疗，避免不适当的手术以及高风险手术。
我们在1995年1月1日至2022年12月31日期间对MEDLINE、Embase和Scopus进行了检索，并查阅了全球和欧洲血管外科学会（ESVS）的指南。共筛选了150篇文章，但仅考虑并纳入了高质量的文章进行叙述性综述。
全球血管指南改进并规范了基于证据的血管重建（EBR）对CLTI患者进行分类和治疗的方法。然而，考虑到并非所有患者都适合血管重建，一个关键策略可能是根据每个患者的个体残余风险概念，通过考虑临床和非临床风险因素对不适合的患者进行分层。最近的BEST-CLI试验证实了自体静脉旁路移植术在CLTI患者血管重建方面优于血管内治疗。然而，无选择的CLTI患者仍然是一个关键问题。
外科医生的经验和技能是治疗和多学科方法的基石。最近的BEST-CLI试验表明，开放手术外周血管手术比侵入性较小的血管内手术能保证更好的结果。
