Current Options in the Diagnosis and Management of Acute Limb Ischemia

Karthikeshwar Kasirajan, MD, Kenneth Ouriel, MD

Prog Cardiovasc Nurs. 2002;17(1)

Conclusion

Atherosclerosis, the major cause of limb ischemia, is a global phenomenon. As such, attention should be directed not only to the limb at risk but to the patient as whole. Hence, modification of systemic risk factors must play an important role in the long-term care of these patients.

In the acute setting, open operative revascularization, thrombolytic therapy, and PMT should not be viewed as competitive treatment modalities. Rather, a synergistic approach should be offered and the disadvantages of each modality must be recognized and minimized. The "ideal" treatment algorithm may be represented by the initial use of a PMT device with or without initial thrombolytic "lacing," followed by thrombolytic infusion to "clean up" residual thrombus. The culprit lesion should then be addressed by open surgical or endovascular means. Only through the efficient use of the multiplicity of interventional strategies can we hope to diminish the morbidity and mortality of acute peripheral arterial occlusion.

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Reprint Address

Address for correspondence: Karthikeshwar Kasirajan, MD, Assistant Professor, Department of Vascular surgery, 2-ACC, University of New Mexico Hospital, 2211 Lomas Blvd., NE, Albuquerque, NM 87131 E-mail: kkasirajan@salud.unm.edu.

References

Table 1. Clinical Categories of Acute Limb Ischemia
Category	Sensory Change	Motor Change	Doppler Signals
Category	Sensory Change	Motor Change	Arterial	Venous
Viable	None	None	Audible	Audible
Threatened	Rest pain	Moderate	Inaudible	Audible
Irreversible	Anesthetic	Paralysis	Inaudible	Inaudible

Table 2. Amputation, Mortality, and Long-Term Limb Salvage With Open Surgery
Author	Year	Number	Amputation	Mortality	Limb Salvage
Campbell et al.^[7]	1998	474	16%	22%	NR
Nypaver et al.^[8]	1998	71	7%	10%	1 year: 62%
Pemberton et al.^[9]	1999	107	12%	25%	2 years: 75%

NR=not reported

Table 3. Contraindications to Use of Pharmacologic Thrombolytic Agents
Absolute Contraindications
Active bleeding disorder Gastrointestinal bleeding within 10 days Cerebrovascular event within 6 months Intracranial or spinal surgery within 3 months Head injury within 3 months
Relative Contraindications
Major surgery or trauma within 10 days Hypertension (systolic >180 mm Hg or diastolic >110 mm Hg) Cardiopulmonary resuscitation within 10 days Puncture of noncompressible vessel Intracranial tumor Pregnancy Diabetic hemorrhagic retinopathy Recent eye surgery Hepatic failure Bacterial endocarditis

Table 4. Results of Treatment With Initial Thrombolytic Therapy or Primary Operation for Acute Limb Ischemia: Multicenter, Randomized Trials
Trial	Patients	Time Period	Thrombolytic Therapy		Primary Operation
Trial	Patients	Time Period	Amputation	Death	Amputation	Death
Rochester^[10]	114	12 months	18%	16%	18%	42%
STILE^[2]	393	6 months	12%	6.5%	11%	8.5%
TOPAS-II^[11]	544	12 months	15%	20%	13.1%	17%

Table 5. Amputation, Mortality, and Patency After Percutaneous Mechanical Thrombectomy
Author	Year	Number	Device	Amputation	Mortality	Patency
Silva et al.^[14]	1998	22	Angiojet	5%	14%	NR
Wagner et al.^[13]	1997	50	Angiojet	8%	0	1 year: 69%
Reekers et al.^[21]	1996	28	Hydrolyser	11%	0	1 month: 50%
Henry et al.^[15]	1998	41	Hydrolyser	0	0	1 month: 73%
Hopfner et al.^[12]	1999	51	Oasis	17.70%	8%	6 months: 54%
Rilinger et al.^[18]	1997	40	Amplatz	5%	0	NR
Tadavarthy et al.^[22]	1994	14	Amplatz	0	0	6 months: 43%

NR=not reported

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