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.

Keywords: acute limb ischemia; endovascular; interventional radiology; thrombectomy; thrombolysis.

Fig. 1

A 65-year-old male presenting with acute-onset right hip and thigh pain with numbness and cold temperature of the right foot starting 16 hours earlier with findings of Rutherford class IIa acute limb ischemia. ( a ) Noninvasive arterial examination confirmed poor perfusion to the right leg with ankle/brachial index 0. ( b–d ) Patient was started on heparin drip and aortography and right lower extremity arteriography confirmed right common femoral embolus. ( e–g ) Catheter-directed thrombolysis was performed, initially into the superficial femoral artery and subsequently into the profundal femoris artery (0.5 mg/hour alteplase over total 12 hours). ( h ) Completion arteriography demonstrated resolution of the embolus with restored in-line flow to the foot confirmed by follow-up physical examination and ( I ) noninvasive arterial examination. Patient was found to have new-onset atrial fibrillation and was continued on anticoagulation. Sup, superficial; Post, posterior; Dors, dorsalis; BP, blood pressure.

Fig. 2

A 79-year-old male with known atrial fibrillation presented with sudden-onset pain and cold temperature of the right leg and foot. His presenting international normalized ratio was 1.4. On physical examination, he was found to have Rutherford class IIb acute limb ischemia. He was started on heparin drip and ( a ) computed tomography angiography confirmed occlusion of the right common and superficial femoral arteries. ( b ) Right lower extremity arteriography confirmed the same with poor distal run-off. ( c and d ) Catheter-directed thrombolysis was initiated from the common femoral through superficial femoral arteries (0.5 mg/hour alteplase for a total of 8 hours). ( e–g ) Follow-up arteriography confirmed revascularization of the common and superficial femoral arteries with residual thromboembolic occlusions of the popliteal artery and infrapopliteal run-off. ( h–j ) Adjunct endovascular thromboembolectomy of the popliteal and infrapopliteal arteries was performed with Penumbra Cat-6 and Cat-3 catheters. ( k and l ) Completion right lower extremity arteriography demonstrated restoration of in-line flow to the right foot. Patient was maintained on therapeutic anticoagulation postoperatively.