PRE-oPerative Assessment for Patients with Chronic Limb ThReatening IschEmia (PREPARE): A Multinational Delphi Consensus.

Background: Chronic limb-threatening ischemia (CLTI) presents significant challenges in both diagnosis and management, with a lack of standardized preoperative assessment and optimization frameworks. This study aimed to establish a contemporary consensus among vascular specialists on the perioperative care of CLTI patients across diverse health-care systems.

Methods: A modified Delphi methodology was used, involving iterative rounds of consultation with 42 expert vascular surgeons from the United Kingdom, Ireland, Australia, and New Zealand. Four broad domains were explored: availability of services, preoperative assessment, perioperative optimization, and the role of multidisciplinary teams (MDTs). Consensus was defined as ≥70% agreement RESULTS: A total of 59 consensus statements were established, covering key areas such as rapid access clinics, the value of preoperative investigations and anemia. Unanimous agreement was reached regarding the necessity of clear referral pathways, and a strong majority supported the importance of MDTs in complex cases. However, significant uncertainty remained about the utility of existing risk prediction models, with only 53% endorsing tools like the American College of Surgeons Risk Calculator. Notably, 81% agreed that if preoperative investigations could change the type of intervention a patient received, this investigation should be performed prior to surgery even at the expense of delayed intervention.

Conclusion: This Delphi consensus study highlights the complexity in managing patients with CLTI and the necessity of a multifaceted, interdisciplinary approach to preoperative care. The findings advocate for improved primary care management, selective use of preoperative investigations and emphasizes the importance of interdisciplinary care. While consensus was reached on several key aspects of care, the study highlights ongoing uncertainties around risk prediction and cardiac stress testing therefore highlighting the need for further research to validate current tools and practices. These results lay the groundwork for future clinical guidelines aimed at reducing practice variability and improving patient outcomes.