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CLI Global Recommendation: An Amputation Should Never Occur Without Proper DSA

Despite recent guideline updates on peripheral artery disease (PAD) and critical limb ischemia (CLI) treatment, the optimal treatment for CLI is still debated resulting in in-consistent care. With evolving diagnostic technology, operators can generate clarity when imaging of target vessels. The CLI Global Society recently published an interdisciplinary expert recommendation for superselective digital subtraction angiography (DSA) that includes the ankle and foot in properly indicated CLI patients to optimize limb salvage.

The CLI Global Society believes the following recommendations may help reduce the incidence of primary amputation in the CLI population, resulting in better outcomes and lower burden on society1:

  1. Primary amputation should not be the first line of treatment for CLI unless there are mitigating circumstances.
  2. An interdisciplinary specialty care team should determine if a CLI limb is salvageable.
  3. A superselective DSA (including the ankle and foot) should be utilized to delineate a salvageable limb prior to amputation.

The Society’s DSA algorithm in conjunction with an interdisciplinary specialty team evaluation can prevent unnecessary amputations or minimize the amputation level in CLI patients.1

figure 1 - proper path to amputation

DSA Algorithm. Digital subtraction angiography algorithm for critical limb ischemia (CLI) patients is shown. From Mustapha JA, et al. Journal of Endovascular Therapy1 used with permission. *Primary amputation should not be the first line of treatment for CLI unless there are mitigating circumstances (eg, life-threatening sepsis, intractable infection, extensive gas gangrene, bedridden status, severe dementia, or tissue loss/necrosis beyond salvage). DUS = duplex ultrasonography; eGFR = estimated glomerular filtration rate; IVUS = intravascular ultrasound1


1. Mustapha JA, Saab FA, Martinsen BJ, et al. Digital Subtraction Angiography Prior to an Amputation for Critical Limb Ischemia (CLI): An Expert Recommendation Statement from the CLI Global Society to Optimize Limb Salvage. Journal of Endovascular Therapy 2020; 1526602820928590. doi: 10.1177/1526602820928590.