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Diagnosis and treatment of acute limb ischemia
Based on the Inter-Society Consensus Edited by Mark R Nehler MD, Associate Professor of Surgery University of Colorado Health Sciences Center, Denver, CO, USA
Supported by an educational grant from Mitsubishi Tanabe Pharma Corporation. Mitsubishi Tanabe Pharma Corporation was not involved in the development of this pocket guide and in no way influenced its contents.

CONTENTS Introduction Acute limb ischemia – definition and nomenclature Evaluation History Present illness Past history Physical examination Clinical classification of acute limb ischemia Differential diagnosis of acute limb ischemia Investigations for acute limb ischemia 4 5 6 6 7 7 8 9 11 13 14 15 15 18 18 19 19 21 21 21 22 23 3 Treatment of acute limb ischemia Endovascular procedures for acute limb ischemia Pharmacologic thrombolysis Surgery Amputation Immediate post-procedural issues Reperfusion injury: compartment syndrome Clinical outcomes Systemic/limb Follow-up care Key points – therapeutic options References .

There are diverse etiologies for ALI. It usually produces new or worsening symptoms or signs. and often threatens limb viability. Timing of presentation is related to ischemia severity1: Patients with embolism. “ALI is associated with a high amputation and mortality rate” 4 5 . General practitioners 2 can play a key role in this respect. trauma. ALI is a sequela 1 Acute limb ischemia – definition and nomenclature ALI is defined as a sudden decrease in limb perfusion that could threaten limb viability. peripheral aneurysms and emboli tend to present early (within hours) due to lack of collaterals and/or extension of thrombus to arterial outflow Later presentations (within days) tend to be restricted to those with native thrombosis or reconstruction occlusion ALI may be the first manifestation of arterial disease in a previously asymptomatic patient or may occur as an acute event that causes symptomatic deterioration in a patient with antecedent lower extremity PAD and intermittent claudication3 of peripheral artery disease (PAD). In this pocket guide. The 30-day mortality and amputation rates are 15% and up to 25–30%. by providing an early and accurate diagnosis. respectively.Introduction Acute limb ischemia (ALI) is a serious medical condition characterized by a rapid decrease in limb perfusion. Outcomes and prognosis of ALI largely depend on the rapid diagnosis and initiation of appropriate and effective therapy. ALI has different etiologies (Figure 1). with the two most common being embolus and thrombosis in situ secondary to underlying disease such as atherosclerosis. the diagnosis and treatment of ALI will be discussed.

g. Etiology of acute limb ischemia4.e.5 Present illness Leg symptoms in ALI relate primarily to pain or limb function. Past history It is important to ask whether the patient has previously had: Leg pain (e. possible embolic sources) Patients should also be asked about serious concurrent disease or atherosclerotic risk factors. onset and severity of limb ischemia (present illness) 2. including: Hypertension Diabetes Smoking 7 History The history should have two primary aims: 1.g. its location and intensity. differential diagnosis and 6 the presence of significant concurrent disease .g. atrial fibrillation) or aneurysms (i. The duration and intensity of the pain and presence of motor or sensory changes are very important Reconstruction/graft thrombosis Trauma (including iatrogenic) Native thrombosis Embolism Peripheral aneurysm with embolus or thrombosis in clinical decision-making and urgency of revascularization. as well as change in severity over time should all be explored. The abruptness and time of onset of the pain. pertaining to etiology. history of claudication. a history of claudication) Interventions for ‘poor circulation’ A diagnosis of heart disease (e. Querying leg symptoms relative to the presence.Figure 1. Evaluation An accurate and thorough initial examination is of prime importance for effective diagnosis and therapeutic management of patients with ALI. recent intervention on the proximal arteries or diagnostic cardiac catheterization). Obtaining background information (e.

However. known as the ‘‘5 Ps’’: Pain: variables include time of onset. location and intensity Pulselessness: the absence of pedal pulses suggests that the patient has ALI.Hyperlipidemia Whether they have a family history of: Cardiovascular disease Strokes Blood clots Amputations Paresthesia: approximately half of patients experience some form of numbness Paralysis: this is a very significant indicator that the patient has a poor overall prognosis Doppler analysis involves the use of an ultrasound scanner to assess blood flow velocity. the patient’s ankle-brachial index (ABI) should be measured immediately to confirm the diagnosis. The three factors that are used to define the severity of the patient’s condition. and hence whether the patient is suitable for revascularization. change over time. It can be used to measure a patient’s ABI and segmental limb pressure Physical examination Patients with ALI may initially present with the following five symptoms. An absent Doppler flow signal in the arteries of the feet is indicative of ALI Pallor: patients with ALI commonly experience 8 changes in color and temperature Clinical classification of acute limb ischemia The severity of ALI is the main consideration that dictates the initial treatment received by the patient. are: The presence of rest pain Sensory loss Muscle weakness 9 .

Is the ischemia caused by an arterial thrombosis or embolus? The conditions that can cause or mimic acute arterial Profound. anesthetic Mild. Irreversible occlusion are listed in Table 2. including the sensory loss and muscle weakness symptoms experienced by the patient (Table 1). 3. Categories of ALI on presentation1 Category I Viable Category II Threatened Category III Nonviable* Data presented summarize both registry and clinical trial data *Some of these patients are moribund Differential diagnosis of acute limb ischemia There are three levels of differential diagnosis in ALI: 1. Immediately threatened Salvageable with immediate revascularization Major tissue loss or permanent nerve damage inevitable More than toes. Viable Not immediately threatened None Muscle weakness None Figure 2. 2.Muscle rigor. moderate III. paralysis (rigor) IIa. Marginally threatened Salvageable if promptly treated Minimal (toes) or none None IIa. A number of different categories are used to identify each stage of ALI. tenderness or findings of pain with passive movement are indicative symptoms of advanced ALI. if not. Separation of threatened from viable extremities6 Findings Category Description/ prognosis Sensory loss I. 10 Reproduced with permission 11 . Table 1. The frequency of different categories of ALI on presentation is shown in Figure 2. Is there a condition mimicking arterial occlusion? Are there other nonatherosclerotic causes of arterial occlusion present and. associated with rest pain Profound.

aneurysm. Differential diagnosis of ALI1 Investigations for acute limb ischemia Routine laboratory studies should be obtained in patients with ALI: Conditions mimicking acute limb ischemia: Systemic shock (especially if associated with chronic occlusive disease) Phlegmasia cerulea dolens Acute compressive neuropathy Differential diagnosis for acute limb ischemia (other than acute PAD): Arterial trauma Aortic/arterial dissection Arteritis with thrombosis (e. plaque or critical stenosis upstream (including cholesterol or atherothrombotic emboli secondary to endovascular procedures) Thrombosed aneurysm with or without embolization Electrocardiogram Standard chemistry Complete blood count Prothrombin time Partial thromboplastin time Creatinine phosphokinase level Patients with a suspected hypercoagulable state will need additional studies seeking: Anticardiolipin antibodies Elevated homocysteine concentration Antibodies to platelet factor IV 12 13 .Table 2.g. thromboangiitis obliterans) HIV arteriopathy Spontaneous thrombosis associated with a hypercoagulable state Popliteal adventitial cyst with thrombosis Popliteal entrapment with thrombosis Compartment syndrome Acute PAD: Thrombosis of an atherosclerotic stenosed artery Thrombosis of an arterial bypass graft Embolism from heart. giant cell arteritis.

Category IIb – immediately threatened. Intravenously administered unfractionated heparin should be used as the standard therapy.Arteriography is of major value in visualizing the distal arterial tree and distinguishing patients who will benefit more from percutaneous treatment than from embolectomy or open surgical procedures. The results of randomized clinical trials demonstrate that both procedures are equally efficacious. Category III – irreversible. This can be achieved through immediate anticoagulation with heparin. Algorithm for management of ALI1 History and physical exam Anticoagulation Doppler α Category I Imaging Revascularization ± Category IIA Imaging Revascularization ± Revascularization* ± Amputation Category IIB Category III Category I – viable. however. *In some centers imaging would be performed Surgical interventions and endovascular procedures are used to treat patients with ALI. unless the patient has antibodies against heparin (Figure 3) 14 15 limb ischemia Pharmacologic thrombolysis Catheter-directed thrombolytic (CDT) therapy is the initial treatment of choice for patients in whom the degree of severity allows time (i.4 Treatment of acute limb ischemia Endovascular procedures for acute The initial goal of treatment for ALI is to prevent thrombus propagation and worsening ischemia. . Other imaging techniques that may be used to examine patients with ALI include: Computed tomographic angiography (CTA) Magnetic resonance (MR) angiography Ideally all patients with ALI should be investigated with imaging. the clinical condition and access to appropriate medical resources may prevent this Figure 3. Category IIa – marginally threatened.e. Categories I and IIa). α – Confirming absent or severely diminished ankle pressure/signals.

prospective studies in ALI. The data from the randomized. major complications and ultimate risk of amputation The advantages of CDT: Reperfusion with CDT is achieved at a lower pressure and may reduce the risk of reperfusion 16 injury compared with open surgery In practice. Alternative non-surgical modalities for the treatment of ALI without the use of pharmacologic thrombolytic agents include: Percutaneous aspiration thrombectomy (PAT) Percutaneous mechanical thrombectomy (PMT) . catheter-based revascularization may be more suitable. CDT offers a lower-risk opportunity for arterial revascularization Using CDT.The choice of lytic therapy depends on several factors including: Location and anatomy of lesions Duration of symptoms Patient risk factors (co-morbidities) Procedural risk If the limb is not immediately or irreversibly threatened. a combination of PAT/PMT and pharmacologic thrombolytic agents is almost always used 17 Combination of PAT/PMT with pharmacologic thrombolysis may substantially speed up clot lysis in advanced ALI where time to revascularization is critical. the underlying lesions can be further defined by angiography When thrombolysis reveals underlying localized arterial disease. These advantages include: Reduced mortality rates Less complex surgical procedure in exchange for a higher rate of failure to avoid persistent or recurrent ischemia. suggest that CDT may offer advantages when compared with surgical revascularization.

resulting in local edema and compartment hypertension.Surgery Surgery may be considered in trauma. The method of revascularization (open surgical or endovascular) may differ depending on: Anatomic location of occlusion Etiology of ALI Contraindications to open or endovascular treatment Local practice patterns Immediate post-procedural issues Reperfusion injury: compartment syndrome Extremity reperfusion leads to increased vascular permeability. but the greatest extent of functional devastation is observed when the deep posterior compartment becomes affected. Fasciotomy is clearly indicated for the treatment of this condition where the compartment pressure is ≥20 mmHg. This condition causes: Regional venule obstruction Nerve dysfunction Capillary and arteriolar obstruction Muscle pain and nerve infarction Amputation Up to 30% of patients with ALI require amputation. or where CDT is not available. paresthesia and edema The most commonly involved compartment is the anterior compartment. . and 10% 18 of patients with ALI present as unsalvageable 19 Clinical symptoms of compartment hypertension include disproportional pain. where there are contraindications to CDT.2 The amputation procedure is usually complicated by: Bleeding (due to an increased prevalence of concomitant anticoagulation) Calf muscle deterioration (which dictates that most of the amputations are above the knee) 10–15% of patients’ limbs thought to be salvageable ultimately require major amputation.

for presumably more severe cases of ALI7 Myoglobinuria occurs in up to 20% of patients following revascularization Half of patients with creatine kinase levels >5000 units/L will develop acute renal failure Urine myoglobin >1142 nmol/L (>20 mg/dL) is also predictive of acute renal failure Clinical outcomes Systemic/limb Mortality rates for ALI range from 15–20%. 5% of patients who have undergone successful revascularization therapy for ALI require fasciotomy 25% of patients in tertiary referral hospitals require fasciotomy treatment. platelet inhibition therapy should be considered. possibly lifelong.The prevalence of fasciotomy treatment: In the United States. Many patients require lifelong anticoagulation due to the high risk of recurrent limb ischemia 20 21 . Patients with thromboembolism will need long-term anticoagulation. If long-term anticoagulation is contraindicated due to bleeding risk factors. Major morbidities include: Due to major bleeding 10–15% of patients require transfusion/and or operative intervention Amputation (25–30% of patients) Fasciotomy (5–25% of patients) Renal insufficiency (up to 20% of patients) Follow-up care All postoperative patients should be given warfarin. often for 3–6 months or longer.

Rajan DK. *Also published as follows: J Vasc Surg 2007. Int Angiol 2007. Hirsch AT. J Vasc Interv Radiol 2005.. Issue 3: CD002784. Surgery versus thrombolysis for acute limb ischaemia: initial management. 4. and abdominal aortic). Eur J Vasc Endovasc Surg 2007. renal. mesenteric. Quality improvement guidelines for percutaneous management of acute limb ischemia. 26(2): 8–157. et al. et al. Br J Surg 1998. 22 23 . 45(Suppl S): S5–67.References Key points – therapeutic options A Doppler assessment should be used to confirm diagnosis of ALI A vascular specialist should evaluate all patients with suspected ALI to determine which therapeutic approach should be used initially All patients with ALI should receive parenteral anticoagulation therapy.org. Campbell WB. 238(3): 382–389. Last accessed October 2007. up to one in four patients suffer major amputation 1. Hiatt WR et al. et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity. A national and single institutional experience in the contemporary treatment of acute lower extremity ischemia. 5. et al. Rutherford RB. 26(3): 517–538.tasc-2-pad. 6. 16(5): 585–595. J Vasc Surg 1997. 3. Cochrane Database Syst Rev 2002. 33(Suppl 1): S1–75. et al. 85(11): 1498–1503. 113(11): e463–654.* 2. Norgren L. Circulation 2006. et al. 7. Ann Surg 2003. The standard treatment used is unfractionated heparin Fasciotomy is the recommended treatment option for patients with compartment syndrome Despite appropriate treatment. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Available at: www. Current management of acute leg ischaemia: results of an audit by the Vascular Surgical Society of Great Britain and Ireland. Recommended standards for reports dealing with lower extremity ischemia: revised version. Eliason JL. Berridge DC.

tasc-2-pad. You can find pocket guides on other topics covered in the TASC II guidelines on the TASC II website: www.TASC II Inter-Society Consensus for the Management of PAD This pocket guide is one of a series of booklets designed to present the TASC II guidelines in a quick reference format. .org © 2008 Discovery London and TASC II. All rights reserved.

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