Current Options in the Diagnosis and Management of Acute Limb Ischemia

Karthikeshwar Kasirajan, MD, Kenneth Ouriel, MD

Prog Cardiovasc Nurs. 2002;17(1)

Immediate Considerations

In 1978, Blaisdell et al.^[4] first introduced the concept of early heparinization to prevent proximal and distal propagation of thrombus, in combination with de-layed intervention. Today, early heparinization remains one of the mainstays in the treatment of ALI. For reasons that are unclear, immediate full-dose heparinization can result in symptomatic improvement in some patients, either from the anticoagulation effects of heparin or volume expansion. Most importantly, immediate and adequate anticoagulation prevents proximal and/or distal thrombus propagation and preserves the microcirculation.

The severity of the ischemia, according to the classification presented above, will dictate the extent of diagnostic tests performed for systemic risk factor assessment. Routine blood studies and coagulation tests should be performed before heparin is administered. Correction of underlying electrolyte imbalances and systemic anticoagulation should proceed concomitantly with the other investigations. A plain chest x-ray and electrocardiogram should be obtained from every patient. In patients with suspected embolism, an echocardiogram should be obtained as soon as time allows. Despite the desirability of a complete work-up, the treatment of an ischemic limb must take priority over more complex and time-consuming investigations.

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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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Current Options in the Diagnosis and Management of Acute Limb Ischemia

Immediate Considerations

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