The most difficult and painful decision: When there is nothing to do anymore, when is better to do nothing

Chronic limb-threatening ischemia (CLTI) is a state of severe malperfusion of the lower limb. Patients with diabetes, end-stage renal disease, or very elderly, are particularly involved and at risk of a major cardiovascular event, sudden death, and amputation. Decision-making in CLTI is based on the initial choice, if attempting limb salvage or proceeding with a major amputation to minimize surgical stress in these fragile patients at risk of perioperative death. It is always important to establish what is their basal functional status, as well as the extent of all their comorbidities, before suggesting a limb revascularization surgery. We should try to understand whether the patient can derive a substantial benefit from a perfectly successful revascularization intervention. Patency or limb salvage should not always be aimed for at any cost: while most patients will benefit from an aggressive limb salvage approach, others will benefit from a primary amputation, and others will benefit from palliative care with no invasive intervention. Therapeutic risk stratification is crucial, and the inability to recover from major stress must be foreseen. We should answer these three questions: Is our patient dying? What is the expected ambulatory capacity of our patient? Is the foot severely infected? Major amputation can also represent the best therapeutic option and, as such, it must be planned and executed with accuracy. Only after this elaborate decision-making process, we can inform our patient to ask for consent to the treatment.