Can we arrange a vascular consult for a patient with critical PAD and cold extremities on Eliquis (apixaban) since we cannot administer IV heparin?

Immediate Transfer to Vascular Specialist Required

Yes, you should immediately arrange a vascular consult, but this is not a substitute for initiating heparin—the patient needs BOTH emergent vascular evaluation AND immediate systemic anticoagulation unless contraindicated. 1

Critical Time-Sensitive Actions

Immediate Anticoagulation is Mandatory

• Systemic anticoagulation with heparin should be administered immediately in patients with acute limb ischemia (ALI) unless contraindicated, regardless of facility limitations or pending vascular consultation 1
• Heparin (generally intravenous unfractionated heparin) stops thrombus propagation and provides an anti-inflammatory effect that lessens ischemia 1
• The patient is already on apixaban (Eliquis), but this does NOT replace the need for IV heparin in ALI—the guidelines specifically recommend heparin for this indication 1, 2
• Skeletal muscle tolerates ischemia for only 4-6 hours, making every minute critical 1

Urgent Vascular Consultation Protocol

• Patients with ALI should be rapidly evaluated by a vascular specialist (vascular surgeon, interventional radiologist, cardiologist, or general surgeon with specialized PAD training) 1
• If vascular expertise is not locally or rapidly available, there should be strong consideration of immediate transfer to a facility with such resources 1
• The more advanced the degree of ischemia, the more rapidly communication about potential patient transfer needs to occur 1

Clinical Assessment Algorithm

Bedside Limb Viability Assessment (Do Not Wait for Imaging)

• Rapidly assess symptom duration, pain intensity, and motor/sensory deficit severity to distinguish threatened from nonviable extremity 1
• Perform arterial and venous examination with handheld continuous-wave Doppler (pulse palpation is inaccurate) 1
• Loss of dopplerable arterial signal indicates the limb is threatened 1
• Absence of both arterial AND venous Doppler signal indicates the limb may be irreversibly damaged (nonsalvageable) 1

Revascularization Timing Based on Limb Category

• Category IIa/IIb (marginally or immediately threatened limbs): revascularization must be performed emergently within 6 hours 1
• Category I (viable limbs): revascularization should be performed urgently within 6-24 hours 1
• Category III (irreversibly damaged): major tissue loss or permanent nerve damage is inevitable 1

Practical Management When Heparin Unavailable at Your Facility

If You Cannot Administer IV Heparin

• Initiate immediate transfer to a facility with both heparin capability AND vascular specialist availability 1
• Do not delay transfer while arranging consultations—time to revascularization directly impacts limb salvage 1
• Communicate the urgency clearly: threatened limbs have a 4-6 hour window for salvage 1

Alternative Anticoagulation Considerations

• If the patient has suspected heparin-induced thrombocytopenia (HIT) with thrombosis, a direct thrombin inhibitor should be given rather than heparin 1
• Check for history of heparin exposure with platelet count decrease before ALI onset 1
• Apixaban alone is insufficient for acute management of ALI—the guidelines specifically call for heparin 1, 2

Common Pitfalls to Avoid

• Do not assume that arranging a vascular consult absolves you of initiating anticoagulation—both are Class I recommendations and must occur simultaneously 1
• Do not wait for imaging before clinical assessment—limb viability assessment does not require imaging and should not delay therapy 1
• Do not rely on pulse palpation alone; use handheld Doppler for accurate vascular assessment 1
• Do not let facility limitations delay definitive care—if you cannot provide heparin, the patient needs immediate transfer 1
• Comorbidities should be investigated and managed aggressively, but this must not delay anticoagulation or vascular consultation 1

Bottom Line

Simply arranging a vascular consult while withholding heparin due to facility limitations is inadequate care for ALI. The 2016 AHA/ACC guidelines are unequivocal: systemic anticoagulation with heparin is a Class I recommendation that should be administered immediately unless contraindicated 1. If your facility cannot provide IV heparin, the patient requires emergent transfer to a facility that can provide both anticoagulation and vascular specialist evaluation, with the urgency of transfer proportional to the degree of limb threat 1.