Recommendations	Grade	Level of evidence	Key references
6.20	Correct inflow disease first when both inflow and outflow disease are present in a patient with CLTI.	Good practice statement
6.21	Base the decision for staged vs combined inflow and outflow revascularization on patient risk and the severity of limb threat (eg, WIfI stage).	1 (Strong)	C (Low)	Harward,80 1995 Zukauskas,81 1995
6.22	Correct inflow disease alone in CLTI patients with multilevel disease and low-grade ischemia (eg, WIfI ischemia grade 1) or limited tissue loss (eg, WIfI wound grade 0/1) and in any circumstance in which the risk-benefit of additional outflow reconstruction is high or initially unclear.	1 (Strong)	C (Low)
6.23	Restage the limb and repeat the hemodynamic assessment after performing inflow correction in CLTI patients with inflow and outflow disease.	1 (Strong)	C (Low)
6.24	Consider simultaneous inflow and outflow revascularization in CLTI patients with a high limb risk (eg, WIfI stages 3 and 4) or in patients with severe ischemia (eg, WIfI ischemia grades 2 and 3).	2 (Weak)	C (Low)
6.25	Use an endovascular-first approach for treatment of CLTI patients with moderate to severe (eg, GLASS stage IA) AI disease, depending on the history of prior intervention.	1 (Strong)	B (Moderate)	Jongkind,82 2010 Ye,83 2011 Deloose,84 2017
6.26	Consider surgical reconstruction for the treatment of average-risk CLTI patients with extensive (eg, GLASS stage II) AI disease or after failed endovascular intervention.	2 (Weak)	C (Low)	Ricco,85 2008 Chiu,86 2010 Indes,87 2013
6.27	Perform open CFA endarterectomy with patch angioplasty, with or without extension into the PFA, in CLTI patients with hemodynamically significant (>50% stenosis) disease of the common and deep femoral arteries.	1 (Strong)	C (Low)	Kang,88 2008 Ballotta,89 2010
6.28	Consider a hybrid procedure combining open CFA endarterectomy and endovascular treatment of AI disease with concomitant CFA involvement (eg, GLASS stage IB inflow disease).	2 (Weak)	C (Low)	Chang,90 2008
6.29	Consider endovascular treatment of significant CFA disease in selected patients who are deemed to be at high surgical risk or to have a hostile groin.	2 (Weak)	C (Low)	Baumann,91 2011 Bonvini,92 2011 Gouëffic,93 2017 Siracuse,94 2017
6.30	Avoid stents in the CFA and do not place stents across the origin of a patent deep femoral artery.	Good practice statement
6.31	Correct hemodynamically significant (≥50% stenosis) disease of the proximal deep femoral artery whenever technically feasible.	Good practice statement