In a patient with acute limb ischemia, should revascularization (revasc) be performed first or fasciotomy?

Revascularization First, Then Fasciotomy for Compartment Syndrome

In acute limb ischemia, revascularization should be performed first to restore blood flow, with fasciotomy reserved for treatment of compartment syndrome after revascularization, not performed prophylactically in most cases. 1

Immediate Management Sequence

Step 1: Rapid Assessment and Anticoagulation

• Immediately administer intravenous unfractionated heparin unless contraindicated, before any procedural intervention 1, 2
• Rapidly assess limb viability using handheld continuous-wave Doppler to categorize the limb (viable, threatened, or irreversibly damaged) 1, 2
• Loss of Dopplerable arterial signal indicates a threatened limb; absence of both arterial and venous signals suggests irreversible damage 2

Step 2: Emergency Revascularization Based on Rutherford Classification

• For immediately threatened limbs (Rutherford IIb): Proceed directly to emergency revascularization within 6 hours without delay for imaging 1
• For marginally threatened limbs (Rutherford IIa): Perform emergent revascularization within 6 hours 1
• For viable limbs (Rutherford I): Perform urgent revascularization within 6-24 hours 1
• For nonsalvageable limbs (Rutherford III): Primary amputation is indicated; revascularization of nonviable tissue should not be performed 1

The critical window is 4-6 hours, which represents the period skeletal muscle will tolerate ischemia 1

Step 3: Post-Revascularization Monitoring for Compartment Syndrome

• All patients must be monitored for compartment syndrome after revascularization 1
• Fasciotomy should be performed when compartment syndrome is diagnosed clinically or when compartment pressure exceeds 30 mmHg with clinical signs 3
• Clinical signs include pain out of proportion to examination, pain on passive stretch, tense compartments, and elevated creatine kinase 3

The Evidence Against Routine Prophylactic Fasciotomy

Prophylactic fasciotomy at the time of revascularization is controversial and may actually worsen outcomes. The most recent high-quality evidence shows:

• A 2024 study demonstrated that prophylactic fasciotomy may not improve amputation-free survival but increases mortality, particularly within the first 30 days, even in high-risk patients 4
• The same study found fasciotomy wound infection rates were significantly higher in the prophylactic fasciotomy group (5.5% vs 1.7%) 4
• However, a 2019 study found that delayed fasciotomy (performed after compartment syndrome develops) was associated with higher risk of major amputation at 30 days (50% vs 5.9%) compared to prophylactic fasciotomy 5

When to Consider Prophylactic Fasciotomy

Despite the general recommendation to avoid routine prophylactic fasciotomy, it may be reasonable in highly selected cases:

• Acute limb ischemia with prolonged or severe tissue ischemia (>6-8 hours of complete ischemia) 3, 2
• Rutherford IIb classification with motor loss or severe sensory deficits 1
• High-energy trauma with tibial fractures, crush injuries, or vascular injuries 3

The ACC/AHA guidelines explicitly state that fasciotomy should be considered when high muscular compartment pressures contribute to occlusion 6, but this is for treatment, not prophylaxis.

Critical Pitfalls to Avoid

• Never delay revascularization to perform prophylactic fasciotomy - restoration of blood flow is the priority 1
• Never rely solely on compartment pressure measurements without clinical correlation - clinical signs are paramount 3
• Never perform fasciotomy on a nonsalvageable limb - this increases morbidity without benefit 1
• Do not wait for late signs like pulselessness and complete sensory loss - these indicate tissue damage is already advanced 3
• If prophylactic fasciotomy is not performed initially and compartment syndrome subsequently develops, recognize that delayed fasciotomy carries higher amputation risk, suggesting a lower threshold for prophylactic fasciotomy in borderline cases 5

Post-Fasciotomy Management (When Performed)

• Leave fasciotomy wounds open initially and plan for delayed closure 3
• Early delayed primary closure can be attempted at a median of 5 days if tissue bulge resolves 3
• Use negative pressure wound therapy to facilitate wound closure or prepare for skin grafting 3
• Monitor for rhabdomyolysis with elevated CPK levels and myoglobinuria to prevent acute kidney injury 3