Development of a standard definition of ‘no-option’ and ‘poor-option’ for revascularization in chronic limb-threatening ischemia

INTRODUCTION: Revascularization to prevent limb loss is not feasible or represents a very high risk in a significant proportion of patients with chronic limb-threatening ischaemia (CLTI). No standard definition currently exists to define this population of patients. The aim of this study was to develop a consensus-based, multidomain definition to improve clinical assessment and reporting of studies in people with 'no option' (NO) or 'poor option' (PO) CLTI. METHODS: A modified Delphi process was conducted with 164 specialists from 30 countries. Two iterative survey rounds were used to reach consensus, defined as ≥70% agreement with a score of ≥7 on a nine-point scale. RESULTS: Some 164 international vascular specialists participated in the study, averaging 19 years of experience. A multidomain framework including arterial disease anatomy, biology, risk, function, and context (ABRFC) achieved 83% consensus. A 'desert foot' was defined as the absence of distal arterial revascularization targets on advanced non-invasive imaging, invasive digital subtraction angiography, and at least one failed endovascular revascularization attempt (81.6% agreement). Inadequate autogenous bypass conduit was defined as the lack of usable autologous vein across all four limbs (85% agreement). Patients were classified as NO for revascularization if they present with 'desert foot', prohibitive medical risk, a non-functional limb, or in those patients who refused arterial revascularization. PO revascularization patients combined factors such as severe infection, lack of autologous vein, or treatment non-compliance (72.1% agreement). CONCLUSION: This consensus study established a structured, expert-validated definition of no option or poor option for revascularisation of patients with CLTI. The multidomain ABRFC framework provides a foundation for standardized clinical assessment, trial design, and future guideline development.

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Publication Details

Journal
British journal of surgery
Published
2026-04-01
DOI
https://doi.org/10.1093/bjs/znag040
Primary Topic
Peripheral Artery Disease Management
Type
article
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article

Development of a standard definition of ‘no-option’ and ‘poor-option’ for revascularization in chronic limb-threatening ischemia

Αθανάσιος Διαμαντόπουλος, Pablo Del Canto Peruyera, Mario Alejandro Fabiani, Luís Loureiro et al.
British journal of surgery
Peripheral Artery Disease Management
article

Development of a standard definition of ‘no-option’ and ‘poor-option’ for revascularization in chronic limb-threatening ischemia

Αθανάσιος Διαμαντόπουλος, Pablo Del Canto Peruyera, Mario Alejandro Fabiani, Luís Loureiro, Giacomo Isernia, Koen Deloose, Bruno Migliara, Jamal J. Hoballah, Martin Maresch, Giacomo Clerici, Kumar Madassery, Gianmarco Falcone, Robert Beasley, Katariina Noronen, Florian Dick, Miltiadis E. Krokidis, Stefano Fazzini, Mariano Palena, Lukla Biasi, Erwin Blessing, Miguel Montero-Baker, Luca Garriboli, Stefano Bonvini, Gianmarco de Donato, Roberto Cancellieri, Dimitrios Miserlis, Lieven Maene, Alexandre Lecis, Masahiko Fujihara, Marta Lobato, Marco Manzi, Caroline Caradu, Amanjit S. Baadh, Lorenzo Patrone, Bella Huasen, Tatsuya Nakama, Elizabeth Genovese, Andrew Holden, Omar Chohan, Fabrizio Fanelli, Jean-Paul de Vries, Mark L. Lessne, Edward Gifford, Prem Chand Gupta, Peter Goverde, M.L. del Río-Solá, Edoardo Pasqui, Giorgio Loreni, Sabeen Dhand, Daniele Morosetti, Andrea Casini, Angelo Cioppa, Esteban Henao, Venita Chandra, Alfredo Verastegui, Karan Garg, Gianbattista Parlani, Sahil Parikh, Vlad Adrian Alexandrescu, Emiliano Chisci, Richard Neville, Dominic Howard, Joseph Mills, Robert Anthony Morgan, Jos C van den Berg, Philippe Kolh, Nasr Bahaa, Marine Leopoldo, Robert Davies, Nicolas Mouawad, Paul Moxey, Patrick Chong, Oscar A De la Torre, Mario D'Oria, Konstantinos Katsanos, Yann Gouëffic, Gonçalo Cabral, Anahita Dua, Grigorios Korosoglou, Bosiers Michel J, Michael Lichtenberg, Larry J Díaz-Sandoval, Siah Michael, Diego Jorge Herrera Vegas, Edward Choke, Jorge Martinez Trabal, Osamu Iida, Luis Morelli Alvarez, Juan Guillermo Barrera Carvajal, Del Giudice Costantino, Raphaël Coscas, Marianne Brodmann, Rafiuddin Patel, Theodosios Bisdas, Stefania Giuffrida, Ashish Patel, S Jay Mathews, Robert Hinchliffe
article en

Abstract

INTRODUCTION: Revascularization to prevent limb loss is not feasible or represents a very high risk in a significant proportion of patients with chronic limb-threatening ischaemia (CLTI). No standard definition currently exists to define this population of patients. The aim of this study was to develop a consensus-based, multidomain definition to improve clinical assessment and reporting of studies in people with 'no option' (NO) or 'poor option' (PO) CLTI. METHODS: A modified Delphi process was conducted with 164 specialists from 30 countries. Two iterative survey rounds were used to reach consensus, defined as ≥70% agreement with a score of ≥7 on a nine-point scale. RESULTS: Some 164 international vascular specialists participated in the study, averaging 19 years of experience. A multidomain framework including arterial disease anatomy, biology, risk, function, and context (ABRFC) achieved 83% consensus. A 'desert foot' was defined as the absence of distal arterial revascularization targets on advanced non-invasive imaging, invasive digital subtraction angiography, and at least one failed endovascular revascularization attempt (81.6% agreement). Inadequate autogenous bypass conduit was defined as the lack of usable autologous vein across all four limbs (85% agreement). Patients were classified as NO for revascularization if they present with 'desert foot', prohibitive medical risk, a non-functional limb, or in those patients who refused arterial revascularization. PO revascularization patients combined factors such as severe infection, lack of autologous vein, or treatment non-compliance (72.1% agreement). CONCLUSION: This consensus study established a structured, expert-validated definition of no option or poor option for revascularisation of patients with CLTI. The multidomain ABRFC framework provides a foundation for standardized clinical assessment, trial design, and future guideline development.

British journal of surgeryVol. 113(4)
University Hospital of Bern (CH), Jacksonville College (US), Massachusetts General Hospital (US), Hospital Zambrano Hellion (MX), Clinica Luganese Moncucco (CH), Tecnológico de Monterrey (MX)
No poverty
Openalex Percentile: Top 36%
Peripheral Artery Disease Management
DOISourceOpenAlex
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