What is the management of chronic lower limb arterial thrombosis with monophasic flow?

Management of Chronic Lower Limb Arterial Thrombosis with Monophasic Flow

Chronic lower limb arterial thrombosis with monophasic flow requires prompt revascularization by a multidisciplinary vascular team, with the specific approach determined by patient factors, lesion characteristics, and available resources. 1

Initial Assessment and Classification

• Rapid evaluation by a vascular specialist is essential to assess limb viability and determine appropriate intervention strategy 1, 2
• Monophasic flow on Doppler indicates significant arterial obstruction, requiring comprehensive vascular imaging (DUS, CTA, MRA) to evaluate revascularization options 1
• Assess severity using clinical signs (rest pain, non-healing wounds, gangrene) and hemodynamic measurements (ankle pressure <50 mmHg, toe pressure <30 mmHg, TcPO2 <30 mmHg) 1

Medical Management

• Initiate systemic anticoagulation with unfractionated heparin immediately unless contraindicated 1
• Start single antiplatelet therapy with either aspirin (75-160 mg daily) or clopidogrel (75 mg daily) for long-term management 1
• Consider dual pathway inhibition with low-dose rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) for patients at high risk of major adverse limb events without high bleeding risk 3, 4
• Long-term dual antiplatelet therapy is not recommended for routine management 1, 5
• Oral anticoagulant monotherapy is not recommended unless there is another indication 1

Revascularization Strategy

• For patients with chronic limb-threatening ischemia (CLTI), revascularization should be performed as soon as possible 1

• The revascularization approach should be determined by:

  • Anatomical lesion location and morphology 1
  • Patient's surgical risk and general condition 1
  • Available local resources and expertise 1

• For femoro-popliteal lesions:

  • Drug-eluting treatment should be considered as first-choice endovascular strategy 1
  • Open surgical approach should be considered when autologous vein (e.g., great saphenous vein) is available in patients with low surgical risk 1

• In multilevel vascular disease, eliminate inflow obstructions when treating downstream lesions 1

Post-Revascularization Care

• Monitor closely for compartment syndrome after revascularization and treat with fasciotomy if clinical evidence develops 1, 2
• After endovascular revascularization, supervised exercise therapy is recommended as adjuvant therapy 1
• For patients undergoing infrainguinal stent implantation, at least 4 weeks of dual antiplatelet therapy with aspirin and clopidogrel is recommended 5

Follow-up Care

• Regular follow-up at least once a year is recommended for all patients with PAD 1
• Follow-up should include assessment of:
  • Clinical and hemodynamic status 1
  • Functional status and limb symptoms 1
  • Medication adherence 1
  • Cardiovascular risk factors 1
  • Duplex ultrasound as needed for new or worsening symptoms 1

Special Considerations and Pitfalls

• Primary amputation should be considered in patients with:

  • Significant necrosis of weight-bearing portions of the foot 1
  • Uncorrectable flexion contracture 1
  • Paresis of the extremity 1
  • Refractory ischemic rest pain 1
  • Sepsis 1
  • Very limited life expectancy due to comorbidities 1

• Bleeding risk assessment is often not standardized and may be underestimated when considering antithrombotic therapy 6

• Standard ankle-brachial index may be normal or falsely elevated in patients with medial sclerosis (common in diabetes or chronic kidney disease), requiring alternative assessments like toe pressure or TcPO2 1