Recommendations for Surgical Revascularization for CLI
COR	LOE	Recommendations
I	A	When surgery is performed for CLI, bypass to the popliteal or infrapopliteal arteries (ie, tibial, pedal) should be constructed with suitable autogenous vein.263,266,269,272
See Online Data Supplement 37.		Many large RCTs have demonstrated that bypasses above the knee should be autogenous vein either reversed or in situ vein.263,266,269,272 There are large single-center trials showing the efficacy of autogenous vein to distal tibial vessels.324,325 In addition, composite sequential femoropopliteal-tibial bypass and bypass to an isolated popliteal arterial segment that has collateral out flow to the foot are both acceptable methods of revascularization and should be considered when no other form of bypass with adequate autogenous conduit is possible.326,327
I	C-LD	Surgical procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene.328–330
See Online Data Supplement 42.		In patients presenting with nonhealing ulcers or gangrene, surgical procedures should be performed to establish in-line blood flow to the foot.328–330 Table 10 addresses factors that may prompt a surgical approach to the patient with CLI.
IIa	B-NR	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.331–333
See Online Data Supplement 42.		There are studies demonstrating that patients for whom endovascular treatment for CLI has failed can be treated successfully with autogenous vein bypass graft332,333 or prosthetic material.331 Although autogenous vein is the preferred conduit for surgical revascularization, prosthetic conduit is a secondary option for patients with CLI without suitable saphenous vein who require surgical revascularization.
IIa	C-LD	A staged approach to surgical procedures is reasonable in patients with ischemic rest pain.334–336
N/A		It is reasonable to perform a staged approach to revascularization in patients with ischemic rest pain with multilevel disease. For example, aortoiliac (inflow) disease may be treated first with endovascular treatment or by surgical reconstruction, depending on lesion characteristics, patient comorbidities, and patient preference.337,338 Combined percutaneous and surgical revascularization may require separate interventions, typically with the most proximal procedure performed first.