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• W4213050403 abstract "This statement was endorsed by the American College of Radiology (ACR), American Podiatric Medical Association (APMA), Society of Interventional Radiology (SIR), Society for Vascular Medicine (SVM), Society for Vascular Surgery (SVS), Society for Clinical Vascular Surgery (SCVS), and Vascular & Endovascular Surgery Society (VESS) in September 2021. This statement was endorsed by the American College of Radiology (ACR), American Podiatric Medical Association (APMA), Society of Interventional Radiology (SIR), Society for Vascular Medicine (SVM), Society for Vascular Surgery (SVS), Society for Clinical Vascular Surgery (SCVS), and Vascular & Endovascular Surgery Society (VESS) in September 2021. Chronic limb-threatening ischemia (CLTI) is the advanced stage of peripheral artery disease (PAD) characterized by rest pain or tissue loss. Up to 2 million individuals have this condition in the United States, and prevalence is anticipated to grow owing to aging of the population and increase in atherosclerotic risk factors such as diabetes and renal disease.1Duff S. Mafilios M.S. Bhounsule P. Hasegawa J.T. The burden of critical limb ischemia: a review of recent literature.Vasc Health Risk Manag. 2019; 15: 187-208Crossref PubMed Scopus (88) Google Scholar In addition to the threat of limb dysfunction and amputation, patients with CLTI are at a high risk of cardio- and cerebrovascular morbidity and mortality, with risk that exceeds that of most other cardiovascular patients. Within 1 year, 1 in 5 CLTI patients dies, and an additional one quarter will require major limb amputation.2Abu Dabrh A.M. Steffen M.W. Undavalli C. et al.The natural history of untreated severe or critical limb ischemia.J Vasc Surg. 2015; 62: 1642-16451, e3Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar Care of the CLTI patient is complex, multifaceted, and multidisciplinary. Medical therapy, wound care, interpretation of noninvasive and invasive vascular testing, and the performance of revascularization procedures are integral to achieve limb salvage. Both surgical and endovascular revascularization have been established as effective treatment modalities that alleviate symptoms and promote healing. Decisions regarding revascularization strategy for individual patients are nuanced and depend in part on comorbidities, anatomy, functional status, conduit availability, presence of suitable bypass target, and other factors. Endovascular revascularization is performed by physicians across a variety of disciplines including vascular surgeons—the only specialty providing both endovascular and open surgical intervention—interventional radiologists, interventional cardiologists, and others.3Goodney P.P. Beck A.W. Nagle J. Welch H.G. Zwolak R.M. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations.J Vasc Surg. 2009; 50: 54-60Abstract Full Text Full Text PDF PubMed Scopus (495) Google Scholar Irrespective of specialty, the endovascular specialist focused on CLTI should understand the role of surgical revascularization, understand the likelihood of short-term and long-term success with each type of revascularization, possess competencies that extend beyond catheter-based therapies, and integrate other CLTI team members into patient care to optimize chances of successful outcomes. Opportunities to improve CLTI care are readily available on many fronts. Failure to prescribe optimal medical therapy to mitigate cardiovascular risk, limited use of smoking cessation programs, and the underutilization of revascularization procedures to prevent limb loss are examples where undertreatment may increase the risk of poor outcomes. However, revascularization failure and the misinterpretation of noninvasive vascular testing to identify macrovascular PAD may also represent scenarios where suboptimal care has been delivered. Evidence from published literature support the existence of these realities in modern CLTI practice.4Moussa Pacha H. Mallipeddi V.P. Afzal N. et al.Association of ankle-brachial indices with limb revascularization or amputation in patients with peripheral artery disease.JAMA Netw Open. 2018; 1e185547Crossref PubMed Scopus (6) Google Scholar,5Nolan B.W. De Martino R.R. Stone D.H. et al.Prior failed ipsilateral percutaneous endovascular intervention in patients with critical limb ischemia predicts poor outcome after lower extremity bypass.J Vasc Surg. 2011; 54 (discussion 735-736): 730-735Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar Moreover, amputation rates are disproportionately worse in blacks and other minorities and individuals of low socioeconomic status.6Lefebvre K.M. Chevan J. The persistence of gender and racial disparities in vascular lower extremity amputation: an examination of HCUP-NIS data (2002-2011).Vasc Med. 2015; 20: 51-59Crossref PubMed Google Scholar,7Arya S. Binney Z. Khakharia A. et al.Race and socioeconomic status independently affect risk of major amputation in peripheral artery disease.J Am Heart Assoc. 2018; 7: e007425Crossref PubMed Scopus (64) Google Scholar To date, few initiatives have been successful in eradicating these CLTI care disparities. One mechanism to improve outcomes in individuals with any disease state is to improve the competency of providers delivering that care. This concept is particularly relevant in CLTI, where much of the care is delivered by physicians in different clinical settings with varied skillsets and unique training experiences. While global guidelines exist surrounding care of the CLTI patient,8Conte M.S. Bradbury A.W. Kolh P. et al.Global vascular guidelines on the management of chronic limb-threatening ischemia.J Vasc Surg. 2019; 69: 3S-125S, e40Abstract Full Text Full Text PDF PubMed Scopus (339) Google Scholar to date, a single CLTI-specific competency document has not been developed.9Creager M.A. Gornik H.L. Gray B.H. et al.COCATS 4 task force 9: training in vascular medicine.J Am Coll Cardiol. 2015; 65: 1832-1843Crossref PubMed Google Scholar,10King S.B. Babb J.D. Bates E.R. et al.COCATS 4 task force 10: training in cardiac catheterization.J Am Coll Cardiol. 2015; 65: 1844-1853Crossref PubMed Scopus (31) Google Scholar This multispecialty societal writing group convened to develop a position statement outlining competencies for endovascular specialists providing CLTI care. Through dissemination and use by clinicians, training programs, and professional societies focused on CLTI, this effort may ultimately enhance the outcomes of this population in need. Although equally important, this document does not address the competencies necessary for optimal vascular surgical care of the patient with CLTI. This document has been developed according to the Society of Cardiovascular Angiography and Interventions (SCAI) Publications Committee policies for writing group composition, disclosure and management of relationships with industry (RWI), internal and external review, and organizational approval. Following proposal submission and approval by the SCAI Publications Committee, professional societies with interest in CLTI care were invited to participate in document development. Each society was asked to nominate one representative to participate in the writing group. Final selections for the writing group were made by the chair and co-chairs (BMH, MS) and the writing group was approved by the SCAI Publications Committee. Ultimately, a diverse and experienced group of content experts was formed with representation from the following societies: American College of Radiology (ACR), American Podiatric Medical Association (APMA), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Interventional Radiology (SIR), Society for Vascular Medicine (SVM), Society for Vascular Surgery (SVS), Society for Clinical Vascular Surgery (SCVS), and Vascular & Endovascular Surgery Society (VESS). The writing group has been organized to ensure diversity of perspectives and demographics, multi-stakeholder representation, and appropriate balance of RWI. Relevant author disclosures are included in Appendix 1. Before appointment, members of the writing group were asked to disclose all financial relationships from the 12 months prior to their nomination. Most of the writing group disclosed no relevant financial relationships. Disclosures were periodically reviewed during document development and updated as needed. SCAI policy requires that writing group members with a current financial interest are recused from participating in associated discussions or voting on relevant recommendations. The work of the writing committee was supported exclusively by SCAI, a nonprofit medical specialty society, without commercial support. Writing group members contributed to this effort on a volunteer basis and did not receive payment from SCAI. Members of the writing group participated in a series of conference calls, jointly developed competencies utilizing the Accreditation Council for Graduate Medical Education (ACGME) core competencies framework,11https://www.acgme.org/Portals/0/MilestonesGuidebook.pdfGoogle Scholar and drafted the final manuscript. All recommended competencies are supported by a short summary of the evidence or specific rationale. The draft manuscript was posted for public comment for 30 days in January 2021 and the document was revised to address pertinent feedback. The writing group unanimously approved the final version of the document. SCAI, ACR, APMA, SCVS, SIR, SVM, SVS, and VESS endorsed the document as official society guidance in September 2021. Care of the CLTI patient is multifaceted, and decidedly more complex and unique compared to individuals with milder forms of PAD and those with other forms of cardiovascular disease. In addition to the well-established risk of cardio- and cerebrovascular morbidity and mortality with CLTI, one glaring distinction relates to the threat of limb loss. Major amputation is a devastating and life-altering event for many patients, and its prevention necessitates coordinated and thorough multidisciplinary care, prescription of optimal medical therapy, treatment of concomitant comorbidities, and prompt revascularization. Unfortunately, many patients do not receive this, and multiple studies have demonstrated that amputations continue to regularly occur without appropriate vascular assessment and revascularization procedures.12Reinecke H. Unrath M. Freisinger E. et al.Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence.Eur Heart J. 2015; 36: 932-938Crossref PubMed Scopus (279) Google Scholar The burden of cardiovascular comorbidities in the CLTI population is well documented. CLTI patients are often elderly and frail, features which increase risks associated with revascularization procedures.13Najafi B. Veranyan N. Zulbaran-Rojas A. et al.Association between wearable device-based measures of physical frailty and major adverse events following lower extremity revascularization.JAMA Netw Open. 2020; 3: e2020161Crossref PubMed Scopus (6) Google Scholar This is highlighted by higher complication rates with surgical bypass compared to endovascular intervention. No randomized trial has shown a survival advantage for endovascular compared to surgical revascularization in CLTI, and a post-hoc analysis suggested an advantage with surgical revascularization in the BASIL trial for those patients who survive >2 years.14Bradbury A.W. Adam D.J. Bell J. et al.Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy.J Vasc Surg. 2010; 51: 5S-17SAbstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar In addition to standard atherosclerotic risk factors like smoking, hypertension, and hyperlipidemia, both diabetes and chronic kidney disease are particularly potent risk factors. Population studies suggest that approximately one half of patients with CLTI have diabetes or end-stage renal disease.15Baubeta Fridh E. Andersson M. Thuresson M. et al.Amputation rates, mortality, and pre-operative comorbidities in patients revascularised for intermittent claudication or critical limb ischaemia: a population based study.Eur J Vasc Endovasc Surg. 2017; 54: 480-486Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar,16Iida O. Nakamura M. Yamauchi Y. et al.Endovascular treatment for infrainguinal vessels in patients with critical limb ischemia: OLIVE registry, a prospective, multicenter study in Japan with 12-month follow-up.Circ Cardiovasc Interv. 2013; 6: 68-76Crossref PubMed Scopus (112) Google Scholar Moreover, symptomatic atherosclerotic disease in other vascular beds is common, with a significant proportion of CLTI patients having had prior acute coronary syndromes and cerebrovascular events.15Baubeta Fridh E. Andersson M. Thuresson M. et al.Amputation rates, mortality, and pre-operative comorbidities in patients revascularised for intermittent claudication or critical limb ischaemia: a population based study.Eur J Vasc Endovasc Surg. 2017; 54: 480-486Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar Recent observational studies have suggested that the burden of these comorbidities in the CLTI population is increasing.17Agarwal S. Sud K. Shishehbor M.H. Nationwide trends of hospital admission and outcomes among critical limb ischemia patients: from 2003-2011.J Am Coll Cardiol. 2016; 67: 1901-1913Crossref PubMed Scopus (171) Google Scholar From an anatomical standpoint, both the severity and distribution of PAD is more complex in those with CLTI compared to that encountered in those with claudication. A retrospective analysis of 450 CLTI patients presenting for revascularization found that multilevel disease (aorto-iliac, femoropopliteal, or below-knee) was present in roughly two thirds, with lengthy occlusive tibial disease being the most commonly encountered lesion phenotype.18Rueda C.A. Nehler M.R. Perry D.J. et al.Patterns of artery disease in 450 patients undergoing revascularization for critical limb ischemia: implications for clinical trial design.J Vasc Surg. 2008; 47 (discussion 999-1000): 995-999Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar The presence of complex tibial disease was even more apparent when examining the cohorts with diabetes and end-stage renal disease. Moreover, infra-mallelolar disease, while known to be a marker of adverse wound healing,19Guzman R.J. Brinkley D.M. Schumacher P.M. Donahue R.M. Beavers H. Qin X. Tibial artery calcification as a marker of amputation risk in patients with peripheral arterial disease.J Am Coll Cardiol. 2008; 51: 1967-1974Crossref PubMed Scopus (99) Google Scholar is a prevalent finding in CLTI limbs. Preliminary data suggest that pedal angioplasty hastens short-term wound healing, but it remains uncertain if this translates into improvements in limb salvage.20Nakama T. Watanabe N. Haraguchi T. et al.Clinical outcomes of pedal artery angioplasty for patients with ischemic wounds: results from the multicenter RENDEZVOUS registry.JACC Cardiovasc Interv. 2017; 10: 79-90Crossref PubMed Scopus (47) Google Scholar Additionally, vessel calcification is common in CLTI patients.19Guzman R.J. Brinkley D.M. Schumacher P.M. Donahue R.M. Beavers H. Qin X. Tibial artery calcification as a marker of amputation risk in patients with peripheral arterial disease.J Am Coll Cardiol. 2008; 51: 1967-1974Crossref PubMed Scopus (99) Google Scholar This anatomic milieu is difficult from an endovascular standpoint and presents extreme technical challenges, often necessitating multilevel procedures (in single or staged fashion), occasionally niche devices to cross and treat complex lesions, and alternate access sites to reach distal lesions or cross chronic total occlusions. Given the complexity and multi-level nature of atherosclerotic disease burden, endovascular therapies in CLTI patients have higher technical failure and complication rates, along with reduced durability compared to similar approaches in the patient with lifestyle-limiting claudication.21Adam D.J. Beard J.D. Cleveland T. et al.Bypass Versus Angioplasty in Severe Ischaemia of the Leg (BASIL): multicentre, randomised controlled trial.Lancet. 2005; 366: 1925-1934Abstract Full Text Full Text PDF PubMed Scopus (1541) Google Scholar, 22Iida O. Takahara M. Soga Y. et al.Three-year outcomes of surgical versus endovascular revascularization for critical limb ischemia: the SPINACH study (Surgical Reconstruction Versus Peripheral Intervention in Patients With Critical Limb Ischemia).Circ Cardiovasc Interv. 2017; 10: e005531Crossref PubMed Scopus (62) Google Scholar, 23Schmidt A. Ulrich M. Winkler B. et al.Angiographic patency and clinical outcome after balloon-angioplasty for extensive infrapopliteal arterial disease.Catheter Cardiovasc Interv. 2010; 76: 1047-1054Crossref PubMed Scopus (166) Google Scholar Accordingly, many patients with severe multilevel disease and CLTI may be better suited for bypass, in particular when there is tissue loss and the need for patency durable enough for wound healing, which often takes >6 months.8Conte M.S. Bradbury A.W. Kolh P. et al.Global vascular guidelines on the management of chronic limb-threatening ischemia.J Vasc Surg. 2019; 69: 3S-125S, e40Abstract Full Text Full Text PDF PubMed Scopus (339) Google Scholar Noninvasive vascular testing is essential in patients with CLTI. Physiologic testing, which includes entities such as the ankle-brachial index (ABI), toe pressures and toe-brachial index (TBI), Doppler waveforms, pulse volume recordings, photoplethysmography, and other perfusion parameters, is paramount in localizing disease, quantifying severity, and assessing for the presence of other pathology beyond macrovascular PAD that may contribute to limb symptoms. Such testing is also useful in quantifying the effects of revascularization, and for surveillance monitoring during short- and long-term follow-up. It is increasingly acknowledged, however, that many of these tests have limitations and are best used in combination with clinical assessment and other objective data to properly manage patients with CLTI. As an example, in a large cohort of more than 10,000 patients receiving revascularization procedures for CLTI, the ABI was normal in 24%, likely owing to vessel calcification from diabetes and renal dysfunction.24Sukul D. Grey S.F. Henke P.K. Gurm H.S. Grossman P.M. Heterogeneity of ankle-brachial indices in patients undergoing revascularization for critical limb ischemia.JACC Cardiovasc Interv. 2017; 10: 2307-2316Crossref PubMed Scopus (20) Google Scholar This emphasizes the importance in CLTI of obtaining and interpreting additional objective perfusion measures such as toe pressures or TBI. Imaging is the other category of noninvasive testing that is frequently used to guide patient management and includes computed tomography angiography (CTA), magnetic resonance angiography (MRA), and duplex ultrasonography (DUS). These studies help localize disease and assist with procedural planning. Importantly, each has limitations, and none may supplant the need for invasive angiography in certain CLTI patients, particularly when infrapopliteal and more distal disease is present. As an example, CTA is less accurate in characterizing tibial disease, particularly in calcified vessels, relative to other imaging modalities.25Mishra A. Jain N. Bhagwat A. CT angiography of peripheral arterial disease by 256-slice scanner: accuracy, advantages and disadvantages compared to digital subtraction angiography.Vasc Endovascular Surg. 2017; 51: 247-254Crossref PubMed Scopus (13) Google Scholar Newer techniques such as time-resolved MRA and dual energy CTA can help with disease characterization in these cases.26Hansmann J. Michaely H.J. Morelli J.N. et al.Impact of time-resolved MRA on diagnostic accuracy in patients with symptomatic peripheral artery disease of the calf station.AJR Am J Roentgenol. 2013; 201: 1368-1375Crossref PubMed Scopus (9) Google Scholar,27Klink T. Wilhelm T. Roth C. Heverhagen J.T. Dual-energy CTA in patients with symptomatic peripheral arterial occlusive disease: study of diagnostic accuracy and impeding factors.Rofo. 2017; 189: 441-452Crossref PubMed Scopus (11) Google Scholar Wound assessment is an integral component of CLTI management. Not all wounds or limb symptoms are attributable to macrovascular PAD. Clinicians evaluating patients with wounds, particularly when revascularization is being considered, must be able to differentiate those of ischemic etiologies from other causes, and be able to initiate the appropriate diagnostic workup and evaluation when non-ischemic lesions are encountered. Basic tenets of wound and podiatric care, as part of a comprehensive CLTI management program, are essential for endovascular specialists before and after revascularization procedures. In summary, revascularization is an important component of CLTI care, but successful patient outcomes are contingent upon the timely and appropriate delivery of numerous other therapies. For endovascular specialists regularly treating CLTI, competency in these unique aspects of CLTI care is needed to eradicate under-treatment and misdiagnosis, avoid preventable amputation, and improve cardiovascular outcomes in this population. The training pathways and mechanisms of competency acquisition for CLTI care will vary between different specialties. Nonetheless, there are common skillsets that all endovascular specialists should possess to facilitate successful outcomes in CLTI patients. Table 1 lists these skillsets and should serve as a framework for the development of tools to assist endovascular proceduralists in assessing and improving competencies. These skills are organized according to the 6 general core competencies used by the ACGME and endorsed by most medical specialty boards.11https://www.acgme.org/Portals/0/MilestonesGuidebook.pdfGoogle Scholar These competency domains are: medical knowledge, patient care and procedural skills, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills.Table 1Competencies for endovascular specialistsMedical knowledge Know peripheral arterial anatomy Know the causes, epidemiology, and natural history of CLTI Know the indications for noninvasive testing for patients with suspected or established CLTI Know the indications for medical therapy and risk factor modification for CLTI Know the indications and contraindications for peripheral angiography Know the indications and contraindications for endovascular and surgical revascularization in CLTI Know the risks and benefits of CLTI revascularization strategies, both endovascular and surgical, and how to tailor each based on patient preference, comorbidities, and anatomy Know the endovascular technologies and techniques available to treat CLTI Know the complications of CLTI revascularization procedures Know the differentiating characteristics between arterial, venous, neurotrophic and atypical lower extremity ulcers Know the basic management of non-CLTI wounds including ancillary testing and referral when appropriate Know the aspects of podiatric care relevant to patients with CLTI Know the principles of radiation safetyPatient care and procedural skills Perform a focused history and physical examination in patients with CLTI Interpret noninvasive vascular imaging, physiologic and perfusion testing in patients with CLTI, before and after revascularization procedures Prescribe medical therapy before and after revascularization to mitigate cardiovascular risk and optimize limb outcomes Select revascularization strategies that are patient-centric and guideline-based, utilizing other specialists where appropriate Perform preoperative risk assessment for patients prior to vascular surgery Evaluate and manage lower extremity wounds, including referring for ancillary testing and specialty care when appropriate Evaluate and manage uncommon vascular disorders and those that may mimic CLTI Perform endovascular revascularization in the aorto-iliac, femoropopliteal, and tibial territories Select and perform alternate access Manage complications related to CLTI procedures Utilize limb surveillance testing after revascularizationSystems-based practice Utilize an interdisciplinary and coordinated approach for CLTI patient management Utilize cost-awareness and risk-benefit analysis in patient carePractice-based learning and improvement Identify and act on performance gaps identified through review of scientific studies, registries, and guidelines Participate in quality improvement initiatives Participate in scientific endeavors aimed at improving CLTI careInterpersonal and communication skills Communicate with and educate patients and families across a broad range of socioeconomic, ethnic, and cultural backgrounds Communicate and work effectively with various professionals on the CLTI teamProfessionalism Practice within the scope of expertise and technical skills Know and promote adherence to guidelines and appropriate use criteria. Interact respectfully and with integrity with patients, families, and all members of the CLTI teamCLTI, chronic limb-threatening ischemia. Open table in a new tab CLTI, chronic limb-threatening ischemia. It is recognized that a spectrum of skillsets exists across many competencies. To account for this range in complexity, examples of competencies were created and stratified into “fundamental” and “advanced” categories and are listed in Table 2. For example, in the case of tibial endovascular revascularization, angioplasty of a tibial artery stenosis is relatively simple in contrast to the treatment of a lengthy calcified tibial chronic total occlusion, where more advanced techniques may be needed. Likewise, the prescription of an antiplatelet and high-potency statin is basic care that should be offered to all patients with PAD, but the initiation of a low-dose direct-acting oral anticoagulant (DOAC) to a CLTI patient to reduce risk of limb events following revascularization could be considered more complex. Note that this framework, in its current iteration, should not be used to restrict the clinical practice of operators not meeting “advanced” criteria, nor should it be used by healthcare systems to compare operators within the same specialty or across differing ones. Indeed, many clinical scenarios exist where advanced skillsets may neither be available nor necessary in order to properly care for a CLTI patient. Rather, this schema identifies the requisite skillsets that all endovascular specialists should possess to provide CLTI care and outlines higher-level competencies that are obtainable and advantageous as they may be impactful in terms of improving outcomes in a greater number of patients with CLTI.Table 2Select examples of advanced and fundamental skillsets for CLTI careCompetency DomainSkillsetFundamentalAdvancedMedical knowledgeAnatomyNoninvasive testingKnow basic aortoiliac, femoropopliteal, and tibial anatomyKnow indications for and types of LE arterial testingKnow tibial variants, know pedal loop anatomyKnow novel imaging and perfusion modalitiesMedical therapyKnow basic medical therapies for PADKnow emerging medical therapies with limb efficacy (eg PCSK9s, DOACs)WoundsDifferentiate basic wound typesKnow the management of non-arterial woundsPatient careNoninvasive testingObtain arterial physiologic testing to quantify and localize PADInterpret venous insufficiency testing to guide management of mixed woundsSystems-based practiceInterdisciplinary careDiscuss angiogram with surgeon to select revascularization modalityDevelop weekly multidisciplinary limb conference to guide patient revascularization managementPractice–based learning and improvementQuality improvementReview complications at regular intervalsParticipate in a longitudinal CLTI registry to benchmark results regionally and nationallyCLTI, chronic limb-threatening ischemia; CTO, chronic total occlusion; DOAC, direct-acting oral anticoagulant; PAD, peripheral artery disease; PCSK9, proprotein convertase subtilisin/kexin type 9; SFA, superficial femoral artery; TASC, Trans-Atlantic Inter-Society Consensus. Open table in a new tab CLTI, chronic limb-threatening ischemia; CTO, chronic total occlusion; DOAC, direct-acting oral anticoagulant; PAD, peripheral artery disease; PCSK9, proprotein convertase subtilisin/kexin type 9; SFA, superficial femoral artery; TASC, Trans-Atlantic Inter-Society Consensus. The medical knowledge competencies were developed to highlight the critical knowledge base required for treatment of CLTI. The parameters for defining clinical success are different when comparing patients presenting with claudication versus those presenting with CLTI. While these distinct clinical presentations may be viewed as a continuum along the disease process of PAD, the overall goals in CLTI are distinct. Moreover, differences exist in the prevalence, presentation, and treatment outcomes of CLTI based on sex, race, and socioeconomic status, and should be recognized by endovascular specialists.28Mentias A. Vaughan-Sarrazin M. Saad M. Girotra S. Sex differences in management and outcomes of critical limb ischemia in the Medicare population.Circ Cardiovasc Interv. 2020; 13: e009459Crossref PubMed Scopus (11) Google Scholar,29Jones W.S. Patel M.R. Dai D. et al.Temporal trends and geographic variation of lower-extremity amputation in patients with peripheral artery disease: results from U.S. Medicare 2000-2008.J Am Coll Cardiol. 2012; 60: 2230-" @default.
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