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Acute limb ischemia

Acute limb ischemia is defined as a sudden decrease in limb blood flow that can lead to potential tissue damage if not promptly treated.
The pathophysiology of acute limb ischemia primarily involves three main causes: embolism, thrombosis, and arterial dissection. Embolism and thrombosis can lead to blockage of blood flow, while arterial dissection can cause a tear in the artery wall, leading to compromised blood flow.
The incidence of acute limb ischemia in the United Kingdom is estimated at 10 per 100,000 person-years.
Disease course
Acute limb ischemia presents with a set of clinical manifestations often referred to as the "5 P's": Pain, Pallor, Pulselessness, Paresthesia, and Paralysis. These symptoms are a result of the sudden decrease in blood flow to the affected limb.
Prognosis and risk of recurrence
The prognosis of acute limb ischemia is influenced by several factors. Early diagnosis and prompt treatment are crucial in preventing severe complications such as limb loss. The prognosis is also influenced by the underlying cause of ischemia and the patient's overall health status.
Key sources
The following summarized guidelines for the evaluation and management of acute limb ischemia are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2023), the Society for Vascular Surgery (SVS 2022), the European Society for Vascular Surgery (ESVS 2020), the American Heart Association (AHA/ACC 2017; 2006), and the American College of Chest Physicians (ACCP 2012).


1.Classification and risk stratification

Severity assessment: use the Rutherford classification for clinical evaluation of patients presenting with acute limb ischemia:
Grade 0, Category 0
Grade I, Category 1
Mild claudication
Grade I, Category 2
Moderate claudication
Grade I, Category 3
Severe claudication
Grade II, Category 4
Ischemic rest pain
Grade III, Category 5
Ischemic ulcers (minor tissue loss)
Grade IV, Category 6
Severe ischemic ulcers or gangrene (major tissue loss)
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2.Diagnostic investigations

Clinical assessment: as per ESVS 2020 guidelines, obtain urgent clinical assessment, performed by a vascular specialist responsible for planning further investigation and management, in patients presenting with a possible diagnosis of acute limb ischemia.

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  • Diagnostic imaging

  • Laboratory testing

  • Evaluation for underlying causes

3.Respiratory support

Supplemental oxygen: administer supplemental oxygen in patients with acute limb ischemia awaiting revascularization.

4.Medical management

Setting of care
Transfer patients diagnosed with acute limb ischemia in a non-vascular center to a vascular center offering the full range of open and endovascular interventions with an urgency depending on the severity of the ischemia.
Ensure that patients with acute limb ischemia have access to treatment in a hybrid theater or operating theater with C-arm equipment and by a clinical team able to offer a full range of open or endovascular interventions during a single procedure.

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  • Anticoagulant therapy

  • Intravenous thrombolysis

  • Pain management

  • Rehydration

5.Therapeutic procedures

Catheter-directed thrombolysis, indications, ESVS: do not perform catheter-directed thrombolysis in patients with acute onset, non-limb-threatening claudication (Rutherford grade I).
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  • Catheter-directed thrombolysis (imaging guidance)

  • Catheter-directed thrombolysis (intraprocedural heparin)

  • Catheter-directed thrombolysis (fibrinolytic agents)

  • Catheter-directed thrombolysis (fibrinogen monitoring)

  • Catheter-directed thrombolysis (monitoring for complications)

  • Mechanical thrombectomy

6.Perioperative care

Perioperative prostacyclin analogs: consider administering prostacyclin analogs during and after open surgical revascularization of patients with acute limb ischemia.

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  • Intraoperative completion imaging

7.Surgical interventions

Surgical thromboembolectomy, indications, ACC/AHA
Determine the revascularization strategy in patients with acute limb ischemia depending on the local resources and patient factors (such as etiology and degree of ischemia).
Consider performing surgical thromboembolectomy in patients with acute limb ischemia secondary to embolism and a salvageable limb.

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  • Surgical thromboembolectomy (anesthesia)

  • Surgical thromboembolectomy (embolectomy catheters)

  • Surgical thromboembolectomy (infrainguinal bypass)

  • Surgical thromboembolectomy (intraoperative local thrombolysis)

  • Hybrid technique

  • Prophylactic fasciotomy

  • Amputation

8.Specific circumstances

Pediatric patients: initiate heparin as initial conservative management of infants and pediatric patients < 2 years of age with acute limb ischemia.
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  • Patients with malignancy

  • Patients with popliteal aneurysm thrombosis

  • Patients with acute aortic occlusion

  • Patients with acute graft occlusion

  • Patients with acute upper limb ischemia

9.Patient education

General counseling: take into account the best interests of the patient before deciding on treatment, obtain informed consent to management if at all possible, and clearly record decisions.

10.Follow-up and surveillance

Post-revascularization monitoring: consider monitoring patients after revascularization, including cardiovascular condition and functional status of the limb.
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  • Post-revascularization anticoagulation

  • Management of post-reperfusion compartment syndrome

11.Quality improvement

Vascular registries: monitor outcomes after treatment of acute limb ischemia in vascular registries using variables developed specifically for this group of patients.