Acute Limb Ischemia Therapies: When and How to Treat Endovascularly

Abstract

Acute limb ischemia is an emergent limb and life-threatening condition with high morbidity and mortality. An understanding of the presentation, clinical evaluation, and initial workup, including noninvasive imaging evaluation, is critical to determine an appropriate management strategy. Modern series have shown endovascular revascularization for acute limb ischemia to be safe and effective with success rates approaching surgical series and with similar, or even decreased, perioperative morbidity and mortality. A thorough understanding of endovascular techniques, associated pharmacology, and perioperative care is paramount to the endovascular management of patients presenting with acute limb ischemia. This article discusses the diagnosis and strategies for endovascular treatment of acute limb ischemia.

Current Treatment Options in Acute Limb Ischemia

“…Since ALI is a clinical diagnosis, further investigations are carried out to confirm etiology and level/location of occlusion and to plan the therapeutic approach (e. g. access side). Based on fast availability, noninvasive imaging methods can be considered equal in patients categorized as IIb according to the Rutherford classification for acute limb ischemia allowing for better therapy planning [12].…”

“…In general, embolic disease should be considered if the occlusion lies at a vessel bifurcation or trifurcation [12].…”

“…However, with the advent of mechanical thrombectomy devices, the treatment time can be minimized and successful utilization in patients with category IIb ALI is reported with increasing frequency [8]. More recent case series reported similar revascularization rates with endovascular treatment with decreased 30-day morbidity and mortality compared to open surgery [12,19].…”

“…In general, patients with category I ALI need urgent revascularization (e. g. within 12 hours of presentation), while patients with category II ALI need emergent revascularization (e. g. within 2-6 hours of presentation) [12].…”

“…The CDT approach is recommended in Category-IIa ALI with a short duration of symptomatology (< 14 days) where the thrombus is still fresh and there is adequate time for the thrombolytic agent to perform its intended function. In the literature, information about dosing and duration of thrombolytic therapy differs extensively and can range between 2.5 and 48 hours in the exemplary case of alteplase [12,29]. The following protocols are recommended: 1. weight-adapted administration of alteplase with 0.001-0.02 mg/kg/h or 2.…”