JOURNAL OF VASCULAR SURGERY

8150 C4 Treatment for Acut« Limb Ischemia J.nuary 2000

C4 Treatment for Acute Limb Ischemia

Acute arterial occlusion can be associated with a spectrum of presenting signs and symptoms
(see Differential Diagnosis, C 2.1.3, P SI37). At one extreme, a patient without underlying
arterial occlusive disease who suffers an acute embolic occlusion at the femoral bifurcation may
present with a profoundly ischemic lower extremity, necessitating urgent intervention. In con-
trast, at the other extreme, an acute embolic or thrombotic occlusion of a chronically diseased
but only partially patent artery may be associated with only mild progression of chronic symp-
toms and modest deterioration in hemodynamics. The problems presented by the acutely
ischemic limb are compounded by inadequate opportunities to treat significant comorbidities
and by the problems after revascularization caused by reperfusion injury. Therefore, the acutely
ischemic limb can present an extreme clinical challenge to the clinician. Despite progress in
many areas of vascular reconstruction, ALI continues to be associated with substantial limb loss
and appreciable mortality, usually attributable to coexistent cardiac disease (10%-20%).1,2,3,4

C4.1 Immediate Management of Acute Limb Ischemia

The treatment of ALI is an emergency situation. Minimizing any delay in relieving the occlu-
sion is essential, because risk of limb loss increases with the duration of the acute ischemia. In
one study, the amputation rates were found to be proportional to the interval between onset of
acute limb ischemia and exploration (6% if within 12 hours, 12% within 13 to 24 hours, and
20% after 24 hours). Most older studies show even higher amputation rates with time. It is
therefore important to eliminate diagnostic measures that are not essential to the needed inter-
vention and to immediately make preliminary arrangements for that treatment, insisting on its
priority.

Pre-intervention anticoagulation with therapeutic levels of heparin reduces morbidity and mor-
tality (compared with not using anticoagulants) and is part of the overall treatment strategy for
these patients.v.? It not only helps prevent clot propagation but, in the case of arterial
embolism, mitigates against another embolus. Therefore, the immediate emergency manage-
ment of all such patients includes heparinization . Administration of heparin may be briefly
delayed in cases in which spinal or epidural anesthesia is important for overall patient manage-
ment. Pain should be controlled by appropriate analgesia. Oxygen inhalation may be helpful,
and there is some experimental evidence of its benefit.f Appropriate treatment for congestive
cardiac failure or atrial or ventricular arrhythmias should be initiated. These and other such sup-
portive measures should be commenced immediately and continued through the intervention,
rather than waiting until after it. Their ultimate importance cannot be overemphasized.

There is no evidence that vasoactive drugs arc helpful in ALI. The same can be said for sympa-
thectomy. Wherever possible, simple measures to improve existing perfusion should be under-
taken, before or after revascularization, or occasionally as an attempt to avoid surgery in a high-
risk patient with marginal viability. These include: keeping the foot dependent, avoiding extrin-
sic pressure over the heel or bony prominence, avoiding temperature extremes (cold induces
vasoconstriction, whereas heat raises the metabolic rate and circulatory demand), maximizing
tissue oxygenation, and correcting hypotension. Used in combination with measures to maxi-
mize cardiac function, these may produce gratifying results.

In summary, although the ischemic limb is the natural focus of attention, the prime considera-
tion should be life rather than limb. The mentioned supportive measures should be an integral
part of the overall management of these patients.

Recommendation 55: Anticoa&lliant therapy in acute limb ischemia

Intravenous heparin at full anticoagulant dosage should be given as soon as the diagno-
sis of acute limb ischemia has been made, provided that heparin is not contraindicated
and that spinal/epidural anesthesia is not planned.
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Volume 31, Number 1, Part 2 C4 Treatmentfor Acute Limb Ischemia S151

Critical Issue 21: Subcutaneous heparin in acute limb ischemia

There is a need to resolve whether intravenous administration of unfractionated heparin
before treatment can be replaced with subcutaneous unfractionated or low-molecular-
weight heparin in the setting of acute limb ischemia.

Recommendation 56: Vasoactive drugs or sympathectomy in acute limb ischemia

There is no evidence that "vasoactive" drugs or sympathectomy are of benefit in the
treatment of acute limb ischemia.

References
1. Golledge 1, Galland RD. Lower limb intra-arterial thrombolysis. Postgrad Med J 1995;71:146-150.
2. Golledge J. Lower-limb arterial disease. Lancet 1997;350:1459-1465.
3. Aune S, Trippestad A. Operative mortality and long-term survival of patients operated on for acute lower extremity ischemia. Eur J
Vase Endovasc Surg 1998;15:143-146.
4. Braithwaite BD, Davies B, Birch PA, Heather BP, Earnshaw n. Management of acute leg ischemia in the elderly. Br J Surg
1998;85:217-220.
5. Panetta T, Thompson JE, Talkington CM, Garrett WV,Smith BL. Arterial embolectomy: a 34-year experiencewith 400 cases. Surg
Clin North Am 1986;66:339-353 ..
6. Blaisdell J:.W, Steele M, Allen RE. Management of acute lower extremity ischemia due to embolism and thrombosis. Surgery
1978;84:822-834.
7. Iivegard L, Holm J, Schersten T. The outcome of arterial embolism misdiagnosed as arterial embolism. Acta Chir Scand
1986;152:251-256.
8. Berridge DC, Hopkinson BR, Makin GS. Acute lower limb arterial ischemia: a role for continuous oxygen inhalation. Br J Surg
1989;76:1021-1023.

C 4.2 Endovascular Procedures for Acute Limb Ischemia

C 4.2.1 Thrombolysis
Formal angiography is performed only in patients in whom the degree of severity allows time
(ie, severity levels I and Ira). In many such patients, depending on other factors (see
Recommendation 57), angiographic findings, catheter-directed thrombolytic therapy is the ini-
tial treatment chosen. The choice depends on location and anatomy of lesions, duration of the
occlusion, the type of clot (embolus vs thrombosis), patient risk (comorbidities), and risk of
procedure (eg, embolectomy under local vs arterial bypass under general anesthesia).
Contraindications to thrombolysis must obviously be observed. However, as a gentler method
of clot removal that potentially may avoid or reduce the scope of open surgery, catheter-directed
thrombolysis is often the initial treatment chosen in levels I and IIa patients. In such instances,
the next step after performing angiography for acute occlusion is to pass a guidewire through
the occluded artery. If the guidewire passes, then intrathrombus lysis should be initiated. If the
catheter fails to pass, regional infusion with the catheter placed proximally may be considered in
an effort to facilitate one subsequent attempt at catheterizing the thrombosed segment.
Regional infusion should not exceed 6 hours before attempting to achieve the optimal catheter
position. Any clinical deterioration during regional infusion should signal the need to discontin-
ue thrombolysis and proceed with surgical revascularization.

Reconunendation 57: Factors for consideration in choosing intervention for acute limb
ischemia
The choice as to which intervention should be used for acute limb ischemia should be based
on
• location and anatomy of lesion
• duration of acute limb ischemia
• type of clot
• patient-related risks
• surgery-related risks
• contraindications to thrombolysis