Recommendations	Grade	Level of evidence	Key references
9.1	Consider transmetatarsal amputation of the forefoot in CLTI patients who would require more than two digital ray amputations to resolve distal necrosis, especially when the hallux is involved.	2 (Weak)	C (Low)	Elsherif,114 2017
9.2	Offer primary amputation to CLTI patients who have a pre-existing dysfunctional or unsalvageable limb, a poor functional status (eg, bedridden), or a short life expectancy after shared decision-making with the patient and health care team.	1 (Strong)	C (Low)	Aziz,115 2015 Siracuse,116 2015
9.3	Consider secondary amputation for patients with CLTI who have a failed or ineffective reconstruction and in whom no further revascularization is possible and who have incapacitating pain, nonhealing wounds, or uncontrolled sepsis in the affected limb after shared decision-making with the patient and health care team.	2 (Weak)	C (Low)	Reed,117 2008
9.4	Consider revascularization to improve the possibility of healing an amputation at a more distal functional amputation level (eg, AKA to BKA), particularly for patients with a high likelihood of rehabilitation and continued ambulation.	2 (Weak)	C (Low)	Rollins,118 1985 Miksic,119 1986
9.5	Consider a TKA or AKA in patients who are nonambulatory for reasons other than CLTI (ie, bedridden patients with flexion contracture, dense hemiplegia, cancer) and are unlikely to undergo successful rehabilitation to ambulation.	2 (Weak)	C (Low)	Ayoub,120 1993 Taylor,121 2008
9.6	Involve a multidisciplinary rehabilitation team from the time a decision to amputate has been made until successful completion of rehabilitation has been achieved.	1 (Strong)	C (Low)	Webster,122 2012
9.7	Continue to observe CLTI patients who have undergone amputation at least yearly to monitor progression of disease in the contralateral limb and to maintain optimal medical therapy and risk factor management.	1 (Strong)	C (Low)	Bradley,123 2006 Glaser,124 2013