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===Recommendation for Revascularization for CLI:=== | ===Recommendation for Revascularization for CLI:=== | ||
{|class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''In patients with CLI, [[revascularization]] should be performed when possible to minimize tissue loss.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | | bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.'''In patients with CLI, [[revascularization]] should be performed when possible to minimize tissue loss.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''An evaluation for [[revascularization]] options should be performed by an interdisciplinary care team before amputation in the patient with CLI.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki> | | bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.'''An evaluation for [[revascularization]] options should be performed by an interdisciplinary care team before amputation in the patient with CLI.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
====Recommendations for Endovascular Revascularization for CLI:==== | ====Recommendations for Endovascular Revascularization for CLI:==== | ||
{|class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or [[gangrene]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki> | | bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.'''Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or [[gangrene]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
{|class="wikitable" style="width:82%" | {| class="wikitable" style="width:82%" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | | colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]) | ||
|- | |- | ||
| bgcolor="LemonChiffon"| | | bgcolor="LemonChiffon" |Pre-endoscopic medical therapy | ||
1. Intravenous infusion of erythromycin (250 mg ~ 30 min before endoscopy) should be considered to improve diagnostic yield and decrease the need for | |||
repeat endoscopy. However, erythromycin has not consistently been shown to improve clinical outcomes | |||
|- | |- | ||
| bgcolor="LemonChiffon"| | | bgcolor="LemonChiffon" |2. Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg / h infusion) may be considered to decrease the proportion of patients who have | ||
higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further | |||
bleeding, surgery, or death | |||
|- | |||
|3. If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding. | |||
|- | |- | ||
|} | |} | ||
{|class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | | colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Use of angiosome-directed endovascular therapy may be reasonable for patients with CLI and nonhealing wounds or [[gangrene]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.'''Use of angiosome-directed endovascular therapy may be reasonable for patients with CLI and nonhealing wounds or [[gangrene]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
| Line 40: | Line 51: | ||
====Recommendations for Surgical Revascularization for CLI:==== | ====Recommendations for Surgical Revascularization for CLI:==== | ||
{|class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' When surgery is performed for CLI, bypass to the popliteal or infrapopliteal arteries (i.e., tibial, pedal) should be constructed with suitable autogenous vein.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki> | | bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' When surgery is performed for CLI, bypass to the popliteal or infrapopliteal arteries (i.e., tibial, pedal) should be constructed with suitable autogenous vein.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Surgical procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or [[gangrene]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | | bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' Surgical procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or [[gangrene]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
{|class="wikitable" style="width:82%" | {| class="wikitable" style="width:82%" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | | colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with CLI for whom endovascular revascularization has failed and a suitable autogenous vein is not available, prosthetic material can be effective for bypass to the below-knee popliteal and tibial arteries. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' In patients with CLI for whom endovascular revascularization has failed and a suitable autogenous vein is not available, prosthetic material can be effective for bypass to the below-knee popliteal and tibial arteries. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' A staged approach to surgical procedures is reasonable in patients with ischemic rest pain. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' A staged approach to surgical procedures is reasonable in patients with ischemic rest pain. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
| Line 62: | Line 73: | ||
===Recommendation for Wound Healing Therapy:=== | ===Recommendation for Wound Healing Therapy:=== | ||
{|class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' An interdisciplinary care team should evaluate and provide comprehensive care for patients with CLI and tissue loss to achieve complete wound healing and a functional foot''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | | bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' An interdisciplinary care team should evaluate and provide comprehensive care for patients with CLI and tissue loss to achieve complete wound healing and a functional foot''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' In patients with CLI, wound care after [[revascularization]] should be performed with the goal of complete wound healing''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | | bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with CLI, wound care after [[revascularization]] should be performed with the goal of complete wound healing''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
{|class="wikitable" style="width:82%" | {| class="wikitable" style="width:82%" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit) | | colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit) | ||
|- | |- | ||
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Prostanoids are not indicated in patients with CLI. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki> | | bgcolor="LightCoral" |<nowiki>"</nowiki>'''1.''' Prostanoids are not indicated in patients with CLI. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
{|class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | | colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with CLI, intermittent pneumatic compression (arterial pump) devices may be considered to augment wound healing and/or ameliorate severe ischemic rest pain. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' In patients with CLI, intermittent pneumatic compression (arterial pump) devices may be considered to augment wound healing and/or ameliorate severe ischemic rest pain. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' patients with CLI, the effectiveness of [[hyperbaric oxygen therapy]] for wound healing is unknown. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' patients with CLI, the effectiveness of [[hyperbaric oxygen therapy]] for wound healing is unknown. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
===References=== | ===References=== | ||
{{Reflist|1}} | {{Reflist|1}} | ||
Revision as of 17:03, 30 November 2017
Recommendation for Revascularization for CLI:
| Class I |
| "1.In patients with CLI, revascularization should be performed when possible to minimize tissue loss.(Level of Evidence: B-NR)" |
| "2.An evaluation for revascularization options should be performed by an interdisciplinary care team before amputation in the patient with CLI.(Level of Evidence: C-EO)" |
Recommendations for Endovascular Revascularization for CLI:
| Class I |
| "1.Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene.(Level of Evidence: B-R)" |
| Conditional recommendation (Class IIa) |
| Pre-endoscopic medical therapy
1. Intravenous infusion of erythromycin (250 mg ~ 30 min before endoscopy) should be considered to improve diagnostic yield and decrease the need for repeat endoscopy. However, erythromycin has not consistently been shown to improve clinical outcomes |
| 2. Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg / h infusion) may be considered to decrease the proportion of patients who have
higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further bleeding, surgery, or death |
| 3. If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding. |
| Class IIb |
| "1.Use of angiosome-directed endovascular therapy may be reasonable for patients with CLI and nonhealing wounds or gangrene. (Level of Evidence: B-NR)" |
Recommendations for Surgical Revascularization for CLI:
| Class I |
| "1. When surgery is performed for CLI, bypass to the popliteal or infrapopliteal arteries (i.e., tibial, pedal) should be constructed with suitable autogenous vein.(Level of Evidence: A)" |
| "2. Surgical procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene. (Level of Evidence: C-LD)" |
| Class IIa |
| "1. In patients with CLI for whom endovascular revascularization has failed and a suitable autogenous vein is not available, prosthetic material can be effective for bypass to the below-knee popliteal and tibial arteries. (Level of Evidence: B-NR)" |
| "2. A staged approach to surgical procedures is reasonable in patients with ischemic rest pain. (Level of Evidence: C-LD)" |
Recommendation for Wound Healing Therapy:
| Class I |
| "1. An interdisciplinary care team should evaluate and provide comprehensive care for patients with CLI and tissue loss to achieve complete wound healing and a functional foot(Level of Evidence: B-NR)" |
| "2. In patients with CLI, wound care after revascularization should be performed with the goal of complete wound healing(Level of Evidence: C-LD)" |
| Class III (No Benefit) |
| "1. Prostanoids are not indicated in patients with CLI. (Level of Evidence: B-R)" |
| Class IIb |
| "1. In patients with CLI, intermittent pneumatic compression (arterial pump) devices may be considered to augment wound healing and/or ameliorate severe ischemic rest pain. (Level of Evidence: B-NR)" |
| "2. patients with CLI, the effectiveness of hyperbaric oxygen therapy for wound healing is unknown. (Level of Evidence: C-LD)" |