From the Guidelines
The management of acute limb ischemia (ALI) involves prompt revascularization to prevent irreversible tissue damage and major amputation.
Revascularization Strategies
- Revascularization should be determined by local resources and patient factors, such as etiology and degree of ischemia 1.
- Both surgical thromboembolectomy and catheter-based thrombolysis are effective therapies for ALI 1.
- Catheter-based thrombolysis is effective for patients with ALI and a salvageable limb, and may offer better survival rates compared to surgery 1.
- The choice of revascularization strategy depends on the clinical presentation, including the presence of neurological deficiencies, and the thrombotic vs. embolic cause 1.
Treatment Approach
- Patients presenting with ALI without contraindications to anticoagulation should receive anticoagulated therapy immediately, usually with heparin 1.
- Treatment options include catheter-directed thrombolysis, mechanical thrombectomy, and surgical thrombectomy, bypass, and/or arterial repair 1.
- Endovascular therapy is the initial treatment of choice, especially in patients with severe co-morbidities, if the degree of severity allows time for revascularization, and pending local availability of an emergency interventional team 1.
- Intra-arterial thrombolysis is the classic endovascular technique for thrombus removal, and various techniques and different thrombolytic agents are currently used 1.
Key Considerations
- The level of emergency and the choice of therapeutic strategy depend on the clinical presentation, mainly the presence of neurological deficiencies, and the thrombotic vs. embolic cause 1.
- Amputation should be performed as the first procedure in patients with a nonsalvageable limb 1.
- All patients should be monitored for compartment syndrome and reperfusion injury 1.
- After initial revascularization, definitive treatment of any underlying culprit lesion can be useful to optimize procedural success and prevent ALI recurrence 1.
From the Research
Diagnosis and Management of Acute Limb Ischemia (ALI)
The management of ALI involves a comprehensive approach, including diagnosis, treatment, and post-procedural care. The diagnosis of ALI is based on clinical data and imaging techniques such as duplex ultrasound, CT angiography, and digital subtraction angiography 2.
Treatment Options
The treatment options for ALI include:
- Pharmacological therapies such as thrombolysis 2, 3
- Interventional techniques such as thromboaspiration, mechanical thrombectomy, and stent implantation 2
- Surgical revascularization techniques such as Fogarty thromboembolectomy, bypass, endarterectomy, and patch angioplasty 2, 4
- Endovascular treatment, including catheter-directed thrombolysis, rheolytic thrombectomy, and utilization of distal protection devices 5
- Amputation, which may be necessary in cases of irreversible damage 2, 6
Post-Procedural Care
Post-procedural care for ALI includes management of reperfusion injury, compartment syndrome, and long-term treatment 2, 4. The decision for endovascular thrombolysis or standard surgery depends on the etiology, duration, and location of vascular occlusion 3.
Classification and Etiology
The classification of ALI is based on clinical variables, and the etiology includes embolism, in situ thrombosis, dissection, and trauma 2, 6. A suspicion of acute ischemia based on history and physical examination warrants heparin administration and vascular surgery consultation 3.